- THE FRONT LINES OF THE OPIOID CRISIS: PERSPECTIVES FROM STATES, COMMUNITIES, AND PROVIDERS

[Senate Hearing 115-870]
[From the U.S. Government Publishing Office]

S. Hrg. 115-870

THE FRONT LINES OF THE OPIOID CRISIS:
PERSPECTIVES FROM STATES,
COMMUNITIES, AND PROVIDERS

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HEARING

OF THE

COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS

UNITED STATES SENATE

ONE HUNDRED FIFTEENTH CONGRESS

FIRST SESSION

EXAMINING THE FRONT LINES OF THE OPIOID CRISIS, FOCUSING ON
PERSPECTIVES FROM STATES, COMMUNITIES, AND PROVIDERS

__________

NOVEMBER 30, 2017

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Printed for the use of the Committee on Health, Education, Labor, and
Pensions

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Available via the World Wide Web: http://www.govinfo.gov

______

U.S. GOVERNMENT PUBLISHING OFFICE

48-380 PDF WASHINGTON : 2022

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky AL FRANKEN, Minnesota
SUSAN M. COLLINS, Maine MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana SHELDON WHITEHOUSE, Rhode Island
TODD YOUNG, Indiana TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas ELIZABETH WARREN, Massachusetts
LISA MURKOWSKI, Alaska TIM KAINE, Virginia
TIM SCOTT, South Carolina MAGGIE WOOD HASSAN, New Hampshire

David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Democratic Staff Director
John Righter, Democratic Deputy Staff Director

C O N T E N T S

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STATEMENTS

THURSDAY, NOVEMBER 30, 2017

Page

Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, opening statement......................... 1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State
of Washington, opening statement submitted for the Record...... 36
Kaine, Hon. Tim, a U.S. Senator from the State of Virginia....... 3
Paul, Hon. Rand, a U.S. Senator from the State of Kentucky....... 5
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 38
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 38

Witnesses

Abubaker, A. Omar, D.M.D, Ph.D., Professor and S. Elmer Bear
Chair, Virginia Commonwealth University School of Dentistry,
Richmond, VA................................................... 6
Prepared statement........................................... 7
Summary statement............................................ 9
Boss, Rebecca, MA, Director, Rhode Island Department of
Behavioral Healthcare, Developmental Disabilities and
Hospitals, Cranston, RI........................................ 10
Prepared statement........................................... 12
Summary statement............................................ 19
Magermans, Andrea, Managing Director, Wisconsin Prescription Drug
Monitoring Program, Wisconsin Department of Regulation and
Licensing, Madison, WI......................................... 19
Prepared statement........................................... 21
Summary statement............................................ 27
Tilley, Hon. John C., Secretary, Kentucky Justice and Public
Safety Cabinet, Frankfort, KY.................................. 28
Prepared statement........................................... 30
Summary statement............................................ 31

THE FRONT LINES OF THE OPIOID CRISIS:
PERSPECTIVES FROM STATES,
COMMUNITIES, AND PROVIDERS

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Thursday, November 30, 2017

U.S. Senate,
Committee on Health, Education, Labor,
and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:04 a.m., in
room 430, Dirksen Senate Office Building, Hon. Lamar Alexander,
Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Murray, Isakson,
Paul, Cassidy, Young, Murkowski, Sanders, Casey, Franken,
Bennet, Whitehouse, Baldwin, Murphy, Warren, Kaine, and Hassan.

Opening Statement of Senator Alexander

The Chairman. Good morning. The Senate Committee on Health,
Education, Labor, and Pensions will please come to order.
Today's hearing is the second in a series of bipartisan
hearings on the opioid crisis. Today we're focused on what is
happening at the state and local levels to address this crisis
that has touched families in every state.
Senator Murray and I will have an opening statement, and
then our Members of this Committee will introduce the
witnesses. I will call on Senator Kaine when I have completed
my opening statement and ask him if he would like to make any
opening remarks and introduce one of our witnesses. I thank him
for being here.
After the witnesses' testimony, Senators will each have 5
minutes of questions.
I mentioned to the witnesses that the subject is a subject
of interest to every single Senator on both sides of the
political aisle, but we're in the midst of a tax debate today,
Senators will be coming in and going.
The toll of the opioid crisis that is ravaging our country
is staggering.
One of our witnesses today, Dr. Abubaker, has experienced
the heartbreak that opioid addiction causes. His son, as a 17-
year-old, was prescribed 90 Vicodin pills for a minor shoulder
injury. He developed an addiction and overdosed 4 years later
on a mixture of drugs, including heroin.
I am grateful that Dr. Abubaker is here to tell his
family's heartbreaking story and share the work he has done to
educate other doctors about prescribing opioids.
As Dr. Abubaker has said, ``People from all walks of life
have had problems. It has nothing to do with where you live or
where you came from. You could be the President. You could be
the son of a doctor.''
Last month, this Committee held the first in a series of
hearings this Congress has had on the opioid crisis, a crisis
that is tearing our communities apart, tearing families apart,
and posing an enormous challenge to health care providers and
law enforcement officials.
That hearing was focused on the federal response to the
opioid crisis, and today we will hear from those on the front
lines. Our witnesses represent states, communities, and
providers who will share what they are doing and what, if any,
changes are needed to federal law to fight the crisis. These
witnesses come from four different states. They have personal
and professional perspectives on the opioid crisis from the
judicial and public health sectors.
We hope to hold an additional hearing early next year as we
build on our work from last Congress, which included passing
the 21st Century Cures Act, appropriating $1 billion over 2
years for state grants, and the Comprehensive Addiction and
Recovery Act, which created new programs to address this
crisis.
I mentioned some of the tragic statistics of this crisis at
our last hearing, but they are worth repeating.
The amount of opioids prescribed in the U.S. in 2015 was
enough for every American to be medicated around the clock for
3 weeks, according to the Centers for Disease Control and
Prevention.
Across the country, 91 Americans die every day from an
opioid overdose.
In my home State of Tennessee, 1,631 Tennesseans died of a
drug overdose last year, 12% more than the year before, mostly
due to an increase in overdoses of synthetic opioids, including
fentanyl, a pain medication that is 50 to 100 times stronger
than morphine and can kill with just a small dose.
It seems that every day there are new studies and
statistics that further describe the toll of this crisis.
For example, last week the White House Office of Economic
Advisers released a report that estimated the opioid crisis
cost $504 billion in 2015.
As we talk about this crisis from a state perspective, I
hope to hear from our witnesses how are different State
Departments--medical, public health, and judicial systems--
working together in a collaborative way to address this crisis?
What innovative approaches are states taking to address the
distinct challenges they face?
For example, Rhode Island is working to connect individuals
who overdose with recovery coaches while they receive treatment
in hospital emergency departments to try to get people into
treatment and break their cycle of addiction in the long term.
The Federal Government remains an important partner in the
opioid crisis. Earlier this month, the President's Commission
on Combatting Drug Addiction and the Opioid Crisis released
recommendations, and I hope our witnesses will touch on some of
those today.
We also want to know what is being done with the tools and
resources provided in the CARA Act and in the Cures Act,
whether these laws are helping make progress, and if not, why
not.
This past spring, the Administration began issuing grants
funded by the Cures Law for states to use in combatting the
opioid crisis. These totaled $485 million to all 50 states.
Because each state is facing different challenges in responding
to the crisis, it is important that states have flexibility in
how to use the money.
Tennessee, for example, received $14 million of that money.
It is using the money to distribute naloxone, a drug that can
reverse an overdose, and train people how to use it to reduce
the number of overdose deaths; to expand access to medication-
assisted treatment; and to implement strategies to help reduce
the number of babies born who experience withdrawal from
opioids. In the last 10 years, Tennessee has seen a nearly ten
fold rise in the incidence of babies born addicted to opioids.
Other states are using the grants from Cures to address
different needs within their states. For example, Arkansas is
using its grant to expand access to buprenorphine, a
medication-assisted treatment.
Other states are using funds to improve state-run
prescription drug monitoring programs, the electronic data
bases that can track controlled substances prescribed by
doctors and dispensed by pharmacists. That way, doctors can see
whether a patient has already been prescribed an opioid by
another doctor across the street.
I'm eager to hear how these programs are run in your states
and if there are things that can be done at the federal level
to help improve coordination and data-sharing at the state
level.
Now I would like to call on the Senator from Virginia,
Senator Kaine, and invite him to make any remarks that he would
like to make and to introduce our first witness, and then I
will introduce the others.

Statement of Senator Kaine

Senator Kaine. Thank you, Mr. Chair. I so appreciate the
opportunity to say some opening words on behalf of my
colleagues, especially Senator Murray. You will see Senators
coming in and out today. I have three hearings going right now,
and there are meetings about tax reform. But you'll see many
Senators here. This is an important topic.
I saw a chart once about 2 years ago about the opioid
problem in the United States. It was unlike any chart I had
ever seen. I was a mayor and Governor before I came to the
Senate, and I'm used to looking at charts, and I often look at
charts that look at various challenges, whether it's low-birth-
weight babies or educational outcomes or percentage of kids in
juvenile detention facilities. I often look at these charts
where they rank states 1 to 50, from best to worst.
Most charts of this kind, the best states are wealthy and
the worst states are poor. It's kind of sad that you can pretty
much put up just a list of states from high per-capita income
to low per-capita income and that's going to tell you where
they are going to be on the measure of virtually any social
challenge.
The opioid chart I saw was completely different, deaths per
100 or per 1,000 to opioid overdoses. I looked at the best 10
states in the country, and there were rich states and poor
states. I looked at the worst 10 states in the country, and
there were rich states and poor states. This is not a problem
that respects race or region or socioeconomic status, and in
that sense it's a very different kind of a challenge than
virtually any challenge that we deal with on this important
Committee.
In Virginia, 1,460 people died of overdoses in 2016, and
that was an 18% increase from the previous year, 2015, even
though we were paying more attention.
We have been riveted upon this problem, with a Governor,
Governor McAuliffe, having appointed a special task force,
declaring a public health emergency in 2013 at the urging of
many of the congressional delegation. But even with this
intense focus and intention, the number of overdose deaths
increased. Eighty percent of those were opioids, and of that
number, 80% of the opioid overdoses were people whose addiction
began when a doctor wrote them a prescription.
The increase in the number of deaths in Virginia, as in
Tennessee, as the Chairman indicated, was largely attributed to
the flooding of the market with fentanyl, a much higher
potency, much more dangerous product.
This is an important hearing to hear what our states are
doing so that we can, hopefully, together with our FDA, our
HHS, our other health research agencies, tackle this challenge.
I think we should try to set a goal as a society to be
addiction free by 2030, just like we set a goal to be on the
moon at the end of the decade in the 1960's.
What we know about the medical aspects of addition, but
also what we know about potential ways to treat, we could do it
if we put our minds and especially our resources to it.
It is my real honor to introduce the first witness today
who is a personal friend, and it's Dr. Omar Abubaker of
Richmond. Dr. Abubaker I first came to know because his
daughter Sarah, who is sitting here in the chamber, worked for
me when I was Governor, and Sarah's brother Joseph is also
here, and this is a wonderful family in Virginia that has had a
horrible story.
Their youngest son Adam, who I met once when I was in line
at a local movie theater with Dr. Abubaker, had a minor
shoulder injury when he was 17 years old playing football, and
he was prescribed 90 Vicodin for this minor shoulder injury.
His dad is a doctor. His dad is a dentist. But like many,
this prescription from an orthopedist seemed like exactly what
should be done and exactly what should be followed for his son
to try to deal with his health challenge.
Instead, that prescription turned into a horrific addiction
and led to Adam's death.
Dr. Abubaker is the endowed Chair and Head of the Oral and
Maxillofacial Surgery Department at Virginia Commonwealth
University. He is a dentist. He is a Ph.D. After his son's
death, he has immersed himself in studying addiction issues,
and also has a certificate in International Addiction Studies
at a program that VCU has started, together with the University
of Adelaide in Kings College, London.
Dr. Abubaker has shared with me as a Ph.D. and a dentist,
in a profession that often prescribes opioid-based medicines,
he thought that he knew a lot. But as he's gotten into the
science of addiction, he realized that even with this extensive
training he knew very little about the science of addiction and
about what are the appropriate ways to deal with pain
management.
He has made it his mission, based on the painful experience
of his family, to try to educate first his students--and the
VCU School of Dentistry is the producer of all the dentists in
Virginia, virtually--first his students, but then others in
what are the right ways to deal with pain and what are the
right ways to prescribe opioids or other medications.
It's a painful thing that really words can't express the
pain that Dr. Abubaker's family has gone through, but his
willingness and his passion and dedication to taking the
experience and educating others so that other families don't
have to go through what his family has experienced is something
I really admire.
Dr. Abubaker, we really appreciate you being here today and
enlightening the Committee.
Senator Alexander will now introduce the other witnesses,
and then he'll ask you to make your opening statement.
Thank you, Senator Alexander.
The Chairman. Thank you, Senator Kaine, for your remarks
and for the introduction.
Welcome, Dr. Abubaker.
I will now ask Senator Paul if he would like to introduce
Secretary Tilley, and then I will introduce the other two
witnesses.

Statement of Senator Paul

Senator Paul. It's my pleasure to introduce Secretary John
Tilley, a great example of how we have a Republican Governor
and at least a Democrat at one time, and maybe still a
Democrat, but bipartisan support for an issue that's not really
a partisan issue to try to fix this.
I have long been an admirer of Mr. Tilley as far as
criminal justice reform, as well as his efforts with this. He's
our Secretary of Kentucky Justice and Public Safety. He's a
native of Hopkinsville, graduate of the University of Kentucky
and Chase College of Law in northern Kentucky, a former
prosecutor known for his work in criminal justice reform. He
also served five terms in the State Legislature.
We're glad to have you here and we look forward to your
testimony.
The Chairman. Thank you, Senator Paul. Welcome, Secretary
Tilley.
Senator Whitehouse and Senator Baldwin will be here before
long, and they'll want to say something about our other two
witnesses. But to give them a brief introduction, Rebecca Boss
is Director of the Rhode Island Department of Behavioral
Healthcare, with more than 25 years of experience in addiction
treatment.
Welcome, Ms. Boss.
Then Andrea Magermans is the Acting Managing Director of
the Wisconsin Prescription Drug Monitoring Program, who has
worked on all aspects of the operations of Wisconsin's Drug
Monitoring Program and helped oversee the development and the
launch of the Wisconsin Enhanced Prescription Drug Monitoring
Program in 2017.
Welcome to you.
We now begin with Dr. Abubaker and ask each of you to
summarize your remarks in about 5 minutes each, and that will
leave time for Senators to ask questions and to have a
conversation with you.
Dr. Abubaker, welcome.

STATEMENT OF A. OMAR ABUBAKER

Dr. Abubaker. Thank you, Chairman Alexander. Thank you,
Senator Kaine, for the kind words. Thank you, other
distinguished Members of the Committee. It's an honor to appear
before you today.
Before today is over, as Chairman Alexander mentioned,
about 91 people will die from opioid overdose. In fact,
approximately 175 Americans will die from all drugs overdose,
91 from opioids. By the end of this year, the death toll from
all drugs overdose in this country will be about 64,000. That
would fill the entire seating assignment for the former RFK
Stadium.
My youngest son, Adam, was one of those people who died
from an opioid overdose. He died from drug overdose early in
the morning of Saturday, September 27th, 2014. He was 21 years
old. Adam did not choose heroin addiction. He volunteered as a
firefighter while he was in high school for 3 years and was
studying to be an EMT at the time of his death. He was
altruistic until the end, donating his organs to save four
lives.
It's difficult to comprehend that a high school football
injury and a medical device to take one to two Vicodin tablets
every four to 6 hours, as needed, for pain led him to addiction
and death. A thousand other parents who have lost their
children to opioids understand my heartbreak. But I'm also a
practicing oral surgeon and an educator, so my pain is
magnified because my profession shares some of that burden.
Since my son's death 3 years ago, hundreds of thousands of
other parents in this country have had the same dreadful phone
call. In Adam's memory, I have become a foot soldier in the war
on addictions, teaching about the proper drug use at my
university and traveling the Commonwealth of Virginia to
advocate for responsible prescribing practices.
In my lectures, I explain to dentists and others the harms
of addiction and over-prescribing. My goal is that each student
and practitioner leaving my class will be less inclined to
prescribe excessive opioids, perhaps protecting one more son or
daughter against the harm of narcotics. That's my effort, and
that is my colleagues at Virginia Commonwealth and VCU Medical
Center.
In Virginia this year, the legislators and the Governor
signed laws that were passed that have led to several
regulations. Just a few of those regulations are limiting the
number of opioid tablets prescribed for acute pain, using
prescription monitoring program, and increasing the
availability of naloxone and training for naloxone use. This
effort has resulted in a marked decrease in the number of
opioid prescriptions since these regulations were enacted in
Virginia, and I can see on the ground that students, residents,
and practitioners have changed their prescribing practices.
Nothing I have done or will do will bring my son back. It
is too late for Adam and others like him. However, we need to
do everything we can to see that such tragedy does not
continue. We need similar or even more legislative steps across
the country to ensure this happens.
Despite the colossal human cost of the opioid crisis, this
is only the tip of the iceberg in terms of human and financial
cost of addictions as a disease. The American Medical
Association and the American Society of Addiction Medicine have
designated addiction as an organic brain disease. Yet, teaching
about it in most health care professional curricula and access
to treatment for those affected is far from what the AMA and
the SA intended it to be. Moreover, the stigma associated with
addictions deter people who are affected from seeking treatment
in the first place because of the shame associated with it.
Many may not be able to access treatment even when they seek
it.
I hope your Committee will keep this in mind as you go
through this hearing. I hope you also do not take your eye off
the ultimate goal that needs to be attained. Please do not
confuse winning the battle against the opioids with winning the
war on addiction, which should be our ultimate goal. We need to
assure funding and coverage for addiction treatment and for
mental illness across the country through state, federal, and
commercial insurance carriers.
We also need to change our entire educational system so
that we will see addiction for what it is, a disease of the
brain. Opioids are only the decoy, but the real foe is
addiction. We need to combat the opioid epidemic so we save our
children. But we also need to regard and treat addiction as a
disease to protect our grandchildren from what may come in the
next 10, 15, or 20 years from now.
Again, thank you very much for your invitation, and I'm
privileged to be here. Thank you.
[The prepared statement of Dr. Abubaker follows:]

------

Prepared Statement of A. Omar Abubaker
Before today is over, approximately 175 people will die from a drug
overdose in our country, and over the next 3 weeks more than 3,500 will
die from the same thing. That is more than all the people who died from
the September 11 terrorist attack.
My youngest son, Adam, overdosed early in the morning of Sept. 27,
2014, on a mixture of heroin and benzodiazepines. He died in the
intensive care unit of a local hospital four days later. He was 21.
Adam didn't choose heroin addiction. He volunteered as a
firefighter while in high school and was studying to be an EMT when he
died. He was altruistic until the end, donating his organs to save four
lives.
Since my son's death 3 years ago, more than 165,000 other parents
in this country have experienced the same agony. Carrying his suffering
and tragic death with me, I have been teaching at my university and
traveling the Commonwealth of Virginia talking about the opioid
epidemic, pain management and addiction to anybody who will listen. My
goal is that each student and practitioner who leaves my class will be
less inclined to prescribe excessive opioids, perhaps guarding one more
son or daughter against the harm of narcotics. Nothing I have done, or
will ever do, will bring my son back. It is too late for Adam and for
another 165,000 like him, but it may not be too late for other fathers
and mothers. I am doing my part to see to it that it is not too late
for these parents. I am praying that all Americans will do their part,
regardless of their political position or role, so that my efforts will
be worth while.
In Virginia, the opioid crisis was declared a public health
emergency in 2016. In the spring of 2017, the following became
regulations to combat the epidemic:

On the prevention front: The Boards of Medicine and Dentistry
enacted regulations (effective May, 2017) to limit opioid prescription
for acute pain to 7 days (14 days for post-surgical pain). The Medical
regulations also drew from the CDC guidelines to require best practices
for the prescribing of opioids for chronic pain (e.g., prescribing of
naloxone if >90 MME, avoiding concomitant opioid and benzodiazepine
prescribing, requiring periodic urine screening, and checking the
Prescription Monitoring Program (PMP) when prescribing opioids for >7
days. Virginia's PMP can identify outlier prescribing or dispensing and
refer to Department of Health Professions enforcement for
investigation. Prescribers are also now required to complete 2
continuing education credits on pain management and opioids as a
requirement for licensure renewal.
Since May, more than 48 prescriber education sessions were held to
make prescribers aware of the new regulations. As a result of these
efforts, there has been a 30% decrease in the number of pills
prescribed in the Commonwealth. On the treatment front, Virginia's new
law includes immunity for naloxone administration, and allows
dispensing of naloxone after state-sanctioned trainings. As a result,
more than 11,000 doses of naloxone have been made available. The new
laws also allow for needle exchange in health districts, in
coordination with local governments. Further, the Virginia Addiction
and Recovery Treatment Services program, a Medicaid waiver to allow
increased reimbursement for the full range of treatment services, has
dramatically increased the number of treatment providers and resources
in Virginia, and is being recognized nationally. Virginia's Department
of Health and Department of Medical Assistance Services (DMAS) worked
extensively in 2016 to increase the number of physicians who are
waivered to prescribe buprenorphine for addiction (Medication-Assisted
Treatment (MAT)). This resulted in increased treatment services with
better quality. In addition, our Department of Medical Assistance
Services, our Medicaid, pulled together insurers, health systems, and
governmental units to develop ARTS (Addiction and Recovery Treatment
Services), a new Medicaid benefit designed to increase treatment for
addiction.
At my institution, Virginia Commonwealth University and VCU Health,
we have been relentless in advancing these issues. Also, at VCU, a
curriculum on the topics of opioids, pain management and addiction has
been initiated. In addition, VCU faculty established a clinic for
treatment of addiction treatment and several measures were adopted in
developing policies and guidelines for pain management and opioid
prescribing for both inpatients and outpatients at the VCU Health
hospitals and clinics.
The initial data show that these legislations and policies are
working. In addition, as I interact with students, residents and
faculty at the university and medical center, and as I travel around
the Commonwealth and talk to dentists, I see a willingness to learn and
change practices by all.
These attempts to change by legislators, educators and doctors in
Virginia can even be more effective if the neighboring states would
adopt similar legislations and guidelines or opioid prescribing and for
educational reforms. In fact, the variation among states makes
individual efforts less effective. If some of these regulations were
federal, and if there are federal mandates for educational changes on
opioid prescribing, pain management and addiction, we will have even
more impact on curbing the epidemic. Encouraging and supporting states
to provide reimbursement for treatment of addiction (just as coverage
of other diseases), and expanding resources and funding training
programs (residency or fellows), we can speed up reining in the
epidemic, and save lives.
The heartbreaking current trail of deaths from drug overdose is
only the tip of the iceberg regarding the current number of deaths from
the disease of addiction. The American Medical Association and American
Society for Addiction Medicine have designated addiction as an organic
brain disease, yet teaching and treating it as such by most Some The
stigma associated with addiction deters people who are affected from
seeking treatment because of the shame. Some may not be able to access
treatment even when they seek it.
I worry that we will not address the root of the current opioid
epidemic, which are addiction and mental illness, as the underlying
reasons for all drug epidemics we have been through and will face in
the future. If we do not address the foundations of these epidemics, I
fear that another drug epidemic will emerge years from now and another
generation of Americans (maybe our grandchildren) will be facing a drug
crisis of different kind. We had better not let that happen. With the
knowledge we have now about brain functions and how addiction affects
it, to let future generations of Americans be affected by a similar
crisis in the future would be an historical abdication of our
responsibility to do good by our country.
Finally, on behalf of the parents and families who lost loved ones,
I am looking to you to act boldly. We need federal reform of all of our
educational systems to include scientific facts about addiction, drugs
and all substances of abuse. We need to prevent the harmful effects of
such exposure through education and by identifying those at risk and
interrupting the disease at its earliest stages. We are also looking to
you to allocate funds in the Comprehensive Addiction and Recovery Act
and in the 21st Century Act coverage, not only for treatment of all
forms of addiction and its underlying mental illness, but also to
extend coverage for screening of those at risk for addiction, brief
interventions and referral for treatment (SBIRT) of those affected. Let
us make ``SBIRT'' the new 5th vital sign in our emergency rooms, doctor
offices and everywhere patients interface with the health care system.
These are historical times in our country's health system, and it can
easily be compared to a plague such as with tuberculosis and AIDS in
our time. I hope you leave your mark on history by acting boldly so
that the loss of our children will not be in vain.
Thank you for giving me the honor and opportunity to speak before
you and I thank you for what you are doing on this front.

______

[summary statement of a. omar abubaker]
Before today is over, approximately 175 Americans will die from a
drug overdose, and over the next 3 weeks, more than 3,500 will die from
the same thing. That is more than all the people who died from
September 11 terrorist attack. My youngest son Adam was one of these
people who died from a drug overdose early in the morning of Sept. 27,
2014. He was 21.

Adam didn't choose heroin addiction. He volunteered as a
firefighter while in high school and was studying to be an EMT when he
died. He was altruistic until the end, donating his organs to save four
lives. It is difficult to comprehend that a high school football injury
and the medical advice to take ``one or two Vicodin tablets every four
to 6 hours as needed for pain'' led him to addiction and death.

Thousands of parents who have lost children to opioids understand
my heartbreak, but I am also a practicing oral and facial surgeon and
an educator so my pain is magnified because my profession shares some
of that burden.

Since my son's death 3 years ago, hundreds of thousands of other
parents in this country have had the same dreadful phone call. Carrying
his life suffering and tragic death with me, I have become a foot
soldier, teaching about proper drug use at my university and traveling
the Commonwealth of Virginia to advocate for responsible prescribing
practices. In my lectures, I explain to dentists and others the harms
of addiction and over-prescribing opioids. My goal is that each student
and practitioner leaving my class will be less inclined to prescribe
excessive opioids, perhaps protecting one more son or daughter against
the harm of narcotics. That is my effort and that of others in our
medical center.

In Virginia, several laws were passed that have led to regulations
for prescribers. These regulations include limiting the number of
tablets prescribed for acute pain, using prescription monitoring
programs, increasing availability of naloxone, increasing the number of
physicians who are waivered to prescribe Medication-Assisted Treatment
(MAT) and recommendations for increasing curricular competencies in
pain management, opioid prescribing, and addiction in Virginia's health
care professional schools.

These efforts have resulted in a marked decrease in the number of
opioids prescribed since the regulations were enacted and I can see the
change in the students', residents', and practitioners' prescribing
practices.

Nothing I have done, or will do, will bring my son back. It is too
late for Adam and others like him. However, we need to do everything we
can to see that such tragedies do not continue! We need similar or even
more legislative steps across the country to assure this happens,
despite the colossal high human cost of the opioid crisis, this burden
is only the tip of the iceberg in terms of the human and financial cost
of addiction as a disease. The American Medical Association and
American Society for Addiction Medicine have designated addiction as an
organic brain disease; yet, teaching about it in most medical
curricula, and access to treatment for those affected, is far from what
the AMA and the ASA intended it to be. Moreover, the stigma associated
to addiction deters people who are affected from seeking treatment
because of the shame. Some may not be able to access treatment even
when they seek it.

I hope your Committee will keep this in mind as you go through
these hearings. I also hope you do not take your eye off the ultimate
goal that needs to be attained. Please ensure that when we win the
battle against the opioid epidemic we do not mistake it for winning the
war on addiction, which should be our ultimate goal. We need to assure
coverage for addiction treatment and for mental illness across the
country through state, federal and commercial insurance carriers.

We also need changes in our entire educational system so that we
all see addiction for what it is--a disease of the brain. Opioids are
the decoy, but the real foe is addiction. We need to combat the opioid
epidemic to save our children, but we also need to regard and treat
addiction as a disease to protect our grandchildren from what may come
next.

Thank you for the giving me the honor and opportunity to testify.

______

The Chairman. Thank you, Dr. Abubaker, and thank you for
your courage and advocacy and for being here today.
Ms. Boss, welcome.

STATEMENT OF REBECCA BOSS

Ms. Boss. Thank you. Chairman Alexander and distinguished
Committee Members, in Rhode Island I am responsible for the
development and oversight of the state's Substance Use
Disorder, Treatment Prevention and Recovery system. I am also a
Board Member of the National Association of the State Alcohol
and Drug Abuse Directors.
Thank you for allowing me to share Rhode Island's work in
combatting the opioid crisis, an effort that has been proposed
as a national model. Our strategies to address this epidemic
are clearly outlined on our website, preventoverdoseri.org.
It's important that our efforts are data driven and publicly
transparent.
First and foremost, I would like to thank Congress for the
federal funding so critical to states through the Department of
HHS agencies, specifically SAMHSA, CDC and HRSA. Additionally,
we are appreciative of the action Congress took passing the
CARA and the 21st Century Cures Act.
Addiction and overdose are claiming lives, destroying
families, and undermining the quality of life across Rhode
Island. Over the last 5 years, our small state has lost more
than 1,200 people to overdose. In 2015, soon after her
election, Rhode Island Governor Gina Raimondo recognized the
need for the state to develop a comprehensive strategy to
reverse this trend. She established the Governor's Overdose
Prevention and Intervention Task Force, Co-Chaired by myself
and the director of the Department of Health. This
multidisciplinary task force is the center of our efforts and
is composed of an array of stakeholders and experts which
represent the kind of partnerships necessary for progress.
We have made significant strides in all four areas of our
strategic plan: prevention, rescue, treatment, and, as you
mentioned, Chairman, recovery. This week, Rhode Island will
announce a 10 percent reduction in overdose rates in 2017. We
are cautious to be overly optimistic in the face of a dynamic
epidemic but can't help but believe we are beginning to see the
results of our efforts.
The battle is far from over. We need to press on. But we
see a glimmer of hope.
Access to treatment is the cornerstone of Rhode Island's
efforts, and we promote that every door is the right door.
Evidence indicates that all three forms of medication-assisted
treatment have life-improving effects on people with opioid use
disorders. It reduced the risk of death, relapse,
incarceration, and greatly improves quality of life.
Federal funding through grants and the Cures Act have
helped Rhode Island promote this treatment through the creation
of Centers of Excellence, supporting MAT and primary care
practices, and supporting psychiatric services for co-occurring
disorders.
With higher vulnerability for overdose, the population of
the Department of Corrections is a focus for intervention. With
every door being the right door, Rhode Island provides MAT
through our combined prison and jail system. The Governor
committed $2 million of state funding in Fiscal Years 2017 and
2018 to this program. All people entering corrections are
screened for opioid use disorders and, if appropriate, are
continued or initiated on MAT. Inmates nearing release are
offered MAT if clinically appropriate.
Now, Rhode Island has successfully implemented a
comprehensive MAT program in the correctional system, with over
300 inmates receiving medications for addiction treatment every
month. Connection to care in the community post-release is 75
percent. Preliminary findings suggest substantial reductions in
overdose mortality for people with recent incarceration. This
is a remarkable achievement considering the high risk posed by
fentanyl circulating in our communities.
The revision of data waiver requirements through CARA has
had a positive impact on our provider capacity. Data waiver
training incorporated into the curriculum of the medical school
at Brown University means that new graduates are eligible to
join fellow physicians in treatment of opioid use disorders
using evidence-based medicine. Rhode Island now has 20 new data
waiver prescribers that are mid-level practitioners. At least
one of Rhode Island's physician assistant programs is offering
clinical rotations through our Center of Excellence.
In Rhode Island, we rely heavily on data to inform our
processes. We have implemented a multidisciplinary overdose
death evaluation team which seeks to gain insight into emerging
trends, identify gaps or opportunities, and inform the
distribution of local funding to communities. The Surveillance
Response and Intervention Workgroup reviews updated overdose
data on a weekly basis to alert communities when activity
exceeds baseline. The community overdose engagement program
calls for task force members to engage with communities in
developing individualized responses when overdose activity
repeatedly exceeds thresholds.
Before concluding, I humbly submit a few recommendations.
Creation of federal regulations and/or funding requirements
that explicitly prohibit discrimination against MAT and the
individuals who receive it. Any federal initiative should
include the involvement of the State Alcohol and Drug agencies.
Our staffs have the expertise and authority that can help chart
the right course.
Increasing funds through the state substance abuse,
prevention and treatment block grant issued through SAMHSA. The
SAPT block grant offers a means to distribute funds effectively
and efficiently and provides opportunity for states to
individualize interventions.
Eliminate the prohibition for the use of federal medicaid
funds to treat incarcerated adults. Rhode Island's experience
demonstrates how a thoughtful approach can reduce overdose and
relapse, encourage recovery, and potentially impact recidivism.
State general revenue dollars cannot be expected to sustain
this effort.
For Rhode Island, the continued availability of Medicaid
expansion and affordable health insurance to support treatment
access is essential to our success, and continued funding
through CARA and the Cures Act.
Thank you for this opportunity, and I look forward to
questions.
[The prepared statement of Ms. Boss follows:]

------

Prepared Statement of Rebecca L. Boss
Chairman Alexander, Ranking Member Murray and Distinguished
Committee Members, my name is Rebecca Boss. I am the Director of the
Department of Behavioral Healthcare, Developmental Disabilities &
Hospitals (BHDDH) and lead the development and oversight of the state's
substance use disorder treatment, prevention and recovery service
system.

It is a privilege to serve my home State of Rhode Island under the
leadership of Governor Gina Raimondo and Secretary of Health and Human
Services Eric Beane.

With more than 25 years' experience in both state government and
the provider community in substance use disorders, and as a Board
Member of the National Association of State Alcohol and Drug Abuse
Directors, also known as NASADAD, I feel that I am uniquely positioned
to testify on this crucial matter.

Thank you for the invitation to appear before you to allow me to
give you Rhode Island's perspective on the Front Lines of the Opioid
Crisis. First and foremost, I wish to thank Congress for the federal
funding that is essential to state agencies like BHDDH that comes to us
through agencies of the Department of Health & Human Services,
specifically SAMHSA, CDC and HRSA.

Furthermore, we are very appreciative of the action Congress took
last year passing the 21st Century Cures Act with $1 billion to help
support prevention, treatment and recovery throughout the country. We
are grateful for the funds which are enabling us to carry out our much-
needed work with Congressional support. As a note, we are supportive of
the revisions to the Cures Act sponsored by Senator Jeanne Shaheen,
which allow funds to flow to the states with ``a prevalence of opioid
use disorders, and a mortality rate associated with opioid use
disorders.'' This change will allow the hardest hit states to move
quickly and with flexibility.

Addiction and overdose are claiming lives, destroying families, and
undermining the quality of life across Rhode Island. For over a decade,
opioid dependence and accidental drug overdose have been growing
problems across the United States, and Rhode Island has been one of the
hardest hit. Over the last 5 years our small state has lost more than
1,200 people to drug overdoses, coming from every community in the
state. That is the equivalent of three Boeing 747's crashing with full
passenger loads--lives needlessly lost.

Our work must be focused on saving lives. RI Governor Gina Raimondo
recognized this and soon after her election in 2015, she knew the state
needed a focused, statewide strategy to evaluate, prevent, and
successfully intervene to reverse the overdose trends. She realized the
scope of the problem had underlying issues, factors and consequence, we
needed a new approach to combat this epidemic. Clearly, something
different had to be created and implemented.

In order to develop a far-reaching approach, the Governor
established the Governor's Overdose Prevention and Intervention Task
Force naming the Directors of BHDDH and the Department of Health (DOH)
as Co-Chairs. The Task Force included stakeholders and experts in
fields ranging from public health and law enforcement to healthcare,
community-based support services, insurance, academia, business,
government and more. A Strategic Plan to Address Opioid Addiction and
Overdose was created which recommended specific, evidence-based
strategies in four areas: prevention, rescue, treatment and recovery.
The plan was data-driven plan and with the help of Brown University, a
web site was created (www.preventoverdoseri.org) where all efforts are
tracked in a public and transparent fashion.

The multi-disciplinary composition of the Task Force became its
distinguishing factor. The Task Force soon became the center of all
opioid overdose prevention and intervention activities in the state.
The perspectives of various individual Members brought cross-learning
to the sectors around the table. Committees were formed in the four
areas of Prevention, Rescue, Treatment and Recovery and everyone went
to work implementing the strategic plan.

Within the four areas of the strategic plan, much was accomplished
in 2016 and thus far in 2017. Individual communities; substance use
treatment, prevention and recovery providers; and law enforcement
officials created many new initiatives. Legislation was passed.
Hospitals and emergency department discharge standards were
implemented. All of this work originated from the Task Force.

Some the initiatives included:

PREVENTION
Safer Prescribing: To achieve safer opioid prescribing, it is
important to weigh the benefits of medication access for patients
living with acute and chronic pain with those of the risks of
diversion, addiction, overdose, and premature death. Unsafe
combinations of prescribed medications are linked to addiction and many
overdoses are preventable.

The key strategy to reduce dangerous prescribing is to use the
Prescription Drug Monitoring Program (PDMP) and system-level efforts to
reduce co-prescription of benzodiazepines with opioids (for pain or
opioid use disorder). Before DOH launched its Prescription Drug
Monitoring Program Enrollment Enforcement Plan in 2016, more than 30
percent of Rhode Island prescribers had failed to enroll in the PDMP,
and fewer than 40 percent were using it. As of July 2016, legislation
had passed that all such practitioners shall be automatically
registered with the Prescription Drug Monitoring Program maintained by
the Department of Health. As of today, 100 percent of practitioners are
enrolled. The state continues to monitor use of the PDMP by prescribers
as well as sending prescriber profiles to practitioners, and providing
academic detailing-or one-on-one office visits-to promote safer opioid
prescribing behaviors.

Additionally, DOH Director, Dr. Alexander-Scott co-led a successful
national petition drive calling on the FDA to require ``black box''
labels on opioids and benzodiazepines warning that concurrent use of
these medications increases the risk of fatal opioid overdose.

Reducing the Supply of Prescribed Opiates (Rx): Rhode Island has
developed regulations that limit most opioid dosing for acute pain
management to a contained period of time (with exceptions for
specifically determined patients) and supports existing hospital policy
to restrict opioid prescriptions from emergency rooms to 3 days or
less.

The promotion of non-opioid therapies for chronic pain, such as
chiropractic services, massage therapy, physical therapy, and
acupuncture as important alternatives to opioid pain relief is another
successful effort in Rhode Island. Access to comprehensive health care
coverage, including Medicaid, is a crucial component of these non-
opioid alternatives.

RESCUE
Naloxone as Standard of Care: Naloxone saves lives by reversing the
severe respiratory depression caused by opioids. Its use by lay people
trained to identify and respond to overdose has been linked to
reductions in overdose death rates. People who use opioids are at
greatest risk of overdose, and are motivated to protect themselves and
others around them to save a life with naloxone. Law enforcement being
equipped with naloxone is critical in the fight against opioid
overdoses. In fact, in Rhode Island two police departments (East
Providence and North Providence) have offered to purchase naloxone for
those departments who may not have the funds to purchase it themselves.
Further, Rhode Island has promulgated regulations requiring all
inpatient substance use disorder providers to offer naloxone to at-risk
clients, Emergency Departments are dispensing naloxone to individuals
who have overdosed, peers distribute on the street, and inmates with
substance use disorders are given naloxone upon release. Fortunately,
Medicaid and commercial insurances cover Naloxone through pharmacies in
RI which allows BHDDH to use other federal funds for additional
prevention and intervention activities. Furthermore, state law mandates
insurance to cover at least one generic form of naloxone, including
naloxone that may be used on a so-called ``third party'': a family
member or friend whose overdose could be reversed by use of naloxone.
Rhode Island has some of the highest naloxone distribution per capita
in the country, and achieving this statistic is an evidence based
approach: public health impact is greatest when the number of naloxone
kits distributed is greater than 20 times the number of annual overdose
deaths, a target that Rhode Island nearly reached in 2016 (target:
6,720, dispensed 6,387 kits) and is on track to exceed in 2017.
TREATMENT
Medication Assisted Treatment: Evidence indicates that medication-
assisted treatment (methadone, buprenorphine or depot naltrexone*
injection) has profound, life-improving effects on people with an
opioid use disorder. It reduces their risk of death, relapse, chance of
going to prison, and greatly improves their quality of life. As a
result, the cornerstone of the Strategic Plan is increasing access to
MAT for individuals in need. The Strategic Plan called for the
development of Centers of Excellence to meet that need. These COEs are
described more fully in sections below.

Rhode Island supports a model of shared decision making between the
individual and their provider. We support the use of FDA-approved
medications for the treatment of opioid use disorder including
methadone, buprenorphine products, and injectable naltrexone, always in
the context of comprehensive clinical and recovery support services.
These supports vary based on patient need, but include drug and alcohol
counseling, screening and treatment of co-occurring mental and physical
health issues, checking of the state prescription drug monitoring data
base, toxicology screening, individual and group therapies, peer
support services, vocational and educational assistance.

As part of the strategic plan implementation, Rhode Island offers
medication-assisted treatment through the combined prison and jail at
the Department of Corrections. Governor Raimondo committed $2 million
in the fiscal year 2017 and fiscal year 2018 for medication for
addiction treatment (MAT) in the state prison system. All people
entering the system are screened for opioid use disorder. Individuals
who are awaiting trial are no longer withdrawn from MAT, and those who
are opioid dependent and not in treatment are able to be inducted on
whichever medication is most appropriate. Sentenced individuals with
histories of opioid use disorder are at a significantly increased risk
of overdose upon release, so these individuals are also being offered
induction on MAT with linkage to care in the community.

With higher vulnerability for overdose, the population of our
Department of Corrections needed a particular focus for intervention.
Now, Rhode Island has a successful implementation of a comprehensive
MAT program in the state correctional system, with over 300 inmates
receiving medications for addiction treatment every month. The
connection to care in the community, post release is 75 percent.
Finally, preliminary findings suggest that there are substantial
reductions in overdose mortality for people with recent incarceration.
This was an expected outcome, given that dozens of studies indicate
that MAT cuts risk of overdose mortality by 50 percent or more. Still,
it is remarkable to achieve such enormous impact despite the
extraordinarily high risk posed by fentanyl circulating in our
communities.

Emergency Department Standards: Leadership from hospitals and
emergency departments throughout Rhode Island joined Governor
Raimondo's Overdose Prevention and Intervention Task Force. RI has
released a first-in-the-nation set of statewide guidelines to save
lives by ensuring consistent, comprehensive care for opioid-use
disorder in emergency and hospital settings. Released in March 2017,
the standards established a common foundation for treating opioid-use
disorder and overdose in Rhode Island hospitals and emergency
departments. The standards establish a three-level system of
categorization that defines each hospital and emergency department's
current capacity to treat opioid-use disorder. All emergency
departments and hospitals in Rhode Island will be required to meet the
criteria for Level 3 facilities, or what we collectively feel are the
essential components of providing humane and consistent care for people
with opioid use disorder treated in Rhode Island. Currently, RI's
hospitals are certified as:

----------------------------------------------------------------------------------------------------------------
Care New England Providence VA
----------------------------------------------------------------------------------------------------------------
LevIn Process-Certified
----------------------------------------------------------------------------------------------------------------
Lev.....................................................
----------------------------------------------------------------------------------------------------------------
Charter Care South County Hospital
----------------------------------------------------------------------------------------------------------------
LevLevel 3-Certified
----------------------------------------------------------------------------------------------------------------
LanWesterly Hospital
----------------------------------------------------------------------------------------------------------------
In process In process
----------------------------------------------------------------------------------------------------------------
Lifespan
----------------------------------------------------------------------------------------------------------------
Lev 1-Certified
----------------------------------------------------------------------------------------------------------------

RECOVERY
Recovery Coaches in Emergency Departments (AnchorED): In May of
2014, Rhode Island started a pilot program using recovery coaches to
respond to overdose survivors while they were receiving treatment in
hospital Emergency Departments. On-call coaches respond to overdose
survivors and offer support, referrals, resources, family support and
training on naloxone. This success of this pilot project supported its
expansion to be offered statewide twenty-four hours per day, 7 days per
week. These coaches have had great success at engaging clients with an
85 percent follow up rate with treatment and/or recovery support
services. This service has provided the state with a wealth of
information on the experience of individuals with the healthcare system
as well as the addiction treatment system. While engaging with recovery
coaches at a crucial point in their addiction, many individuals make
the decision that they are ready for treatment--seeing the hope of
recovery through shared experience and recognizing their desperate
state makes people ready for change.

Anchor MORE: The success of AnchorED spurned the development of
AnchorMORE, recognizing that successful consumer engagement does not
have to wait for an individual to show up at an ED with an overdose.
The Anchor MORE is a community outreach program, placing recovery
coaches on the streets to connect with and engage individuals. Anchor
MORE currently dispatches these teams of recovery coaches to areas in
which individuals are using substances in public places. Anchor MORE
teams are also proactively dispatched to certain areas in the state by
looking at overdose data and emergency services pick-up data. Both
programs connect individuals with recovery coaches--trained peers with
lived experience of addiction. Recovery coaches stay actively engaged
with individuals after an encounter and connect them to treatment and
recovery support services.

Recovery Coaches in the Department of Corrections: The RI
Department of Health has a contract with Anchor Recovery to provide
peer recovery coaches to inmates prior to release from the Department
Corrections, continuing this connection post release. The Anchor
Recovery Center offers a ``Welcome Home'' group to those who
participate in this program, maintaining crucial positive support at a
critical time.

THE IMPACT OF FEDERAL PROGRAMS, POLICIES AND FUNDING
Revision of Data Waiver Requirements through CARA: Rhode Island is
leading the way with the training of medical students, the first of its
kind in the country. The 2018 Class of the Warren Alpert Medical School
of Brown University, which will graduate next May, will be the first
class to participate in a new program to complete the training
necessary to qualify for a Drug Abuse Treatment Act of 2000 (DATA 2000)
waiver prior to graduation. Once the new graduates receive their full
medical license and DEA registration, they can apply for the DATA 2000
waiver and join fellow physicians in the treatment of opioid use
disorders using evidence based medicine.

Rhode Island has more than 350 Data-waivered providers, allowing
for the treatment of up to 24,735 patients. RI has 20 new data waivered
prescribers that are mid-level practitioners. At least one of RI's
Physician Assistant programs is offering clinical rotations through
RI's Centers of Excellence for treatment of opioid use disorders.

Medication Assisted Treatment--Prescription Drug and Opioid
Addiction (MAT-PDOA) Program: This grant program has enabled RI to
create and fund Centers of Excellence (COE) for Opioid Use Disorders.
Centers of Excellence are the cornerstone of Governor Raimondo's Action
Plan, which was created by the Governor's Overdose Prevention and
Intervention Task Force.

COEs provide a means of rapid access to treatment for opioid use
disorder, provide comprehensive services and work collaboratively with
community providers of ongoing treatment for the opioid use disorder
once stabilized in the Center of Excellence. This model also provides
additional support to community providers-be they physicians or other
allied providers, or community treatment programs that may not be
equipped to assist a person who experiences relapse to opioid use by
re-admitting the person to the Center for any additional stabilization
needed. These Centers also serve to assist with the workforce
development needs of our state in that these centers provide practical
educational experiences in opioid use disorder treatment to community
providers and trainees alike. Centers of Excellence are funded through
private third party insurers as well as Medicaid. With Medicaid
expansion, many more people are able to access Medication Assisted
Treatment for opioid addiction. Currently, there are nine operating
Centers of Excellence in Rhode Island. The newest COE to open is on the
campus of Butler Hospital in
Providence and is open 24/7.

State Targeted Response (STR) Grant: The STR has been very
impactful in Rhode Island. These funds allowed the state to supplement
existing opioid program activities and supports a comprehensive
response to the opioid epidemic through integrated planning and
monitoring.

Specifically, this one grant:

Provides five nurse care managers to five high-risk
communities to increase the use of MAT in large primary care
practices ($500,000)

Provides psychiatry services to the Centers of
Excellence and the Opioid Treatment Programs to address co-
occurring disorders in an under served population ($500,000)

Implements the Recovery Housing Pilot with 40 level
three beds for those at risk ($536,825)

Provides OTPs with fentanyl testing kits for regular
screenings to enhance targeted interventions ($60,000)

Incentivizes practitioners to become DATA waivered
($75,000)

Funds local community implementation of evidence based
prevention strategies to five at-risk communities ($240,066)

Provides naloxone kits to the Department of
Corrections and to Rhode Island's Mobile Outreach and Education
Program for distribution in targeted at-risk locations
($99,975)

Provides added funding to the state's awareness
campaign for opioid use disorders ($50,000)

National Institute on Drug Abuse: Grant awarded to Rhode Island
Hospital, working in partnership with the state to develop pharmacy-
based MAT provision for maintenance with buprenorphine and naltrexone.
This will create and then research the effectiveness of pharmacy
management of MAT for people with opioid use disorder, a first in the
country that has the potential to expand access to MAT the way that
pharmacies have helped to expand access to naloxone across the state.

Coordination Between federal, state and local agencies: The
Governor's Overdose Prevention and Intervention Task Force is truly the
hub of all activity in the fight against the opioid epidemic. The Task
Force includes stakeholders and experts in fields ranging from public
health and law enforcement to healthcare, community-based support
services, insurance, academia, business, government and more. Family
members of those who lost loved ones are also part of the Task Force,
and have added an invaluable perspective that we in government and the
private sector sometimes miss.

The Task Force was created in August of 15, a Strategic Plan was
presented to the Governor in December 2015, an Action Plan was created
and released in May 2016, and a Public Awareness campaign was unveiled
in June 2016.

Today, Governor Raimondo continues to make turning the tide on the
opioid crisis a top priority for her administration. Like so many Rhode
Islanders, she has her own stories of personal connection and loss to
the opioid epidemic, and she has encouraged agencies across our state
government to be bold, creative, and determined in developing a
response to opioid crisis. In July 2017, the Governor used her
executive authority to direct state agencies, including the Department
of Behavioral Healthcare, Developmental Disabilities, and Hospitals, to
undertake a series of actions on opioid policy that fit into our core
areas of emphasis: prevention, rescue, treatment, and recovery.

On prevention, the Governor's executive order directed Rhode Island
agencies to build from existing work that uses opioid prescriber data
to target top prescribers of opioids in state and give those providers
specific guidance on reducing unnecessary prescriptions, and we are
developing creative, data-driven ways to ``nudge'' people who get
opioid prescriptions to properly dispose of excess medication in order
to reduce the risks that those prescriptions end up in the wrong hands.
On rescue, the Executive Order also pushed agencies to place more
naloxone in community settings so that anyone with the proper training
can administer the naloxone and reverse the effects of an overdose. All
hospitals in Rhode Island are on their way to having a ``level of
care'' designation for opioid use disorder treatment, which guarantees
a set standards for opioid use disorder care, regardless of where a
patient is admitted in our state.

For treatment and recovery, the Executive Order also asked agencies
to hire medical professionals in high-risk communities who will help
people get access to long-term treatment and recovery options,
including long-term medication assisted treatment, and we continue to
remove barriers that stand in the way of linking every Rhode Islander
with substance use disorder to a peer recovery coach who can help be an
ally and mentor to people in recovery. The Governor's executive order
also directed agencies to do more to support Rhode Island's Centers of
Excellence on substance use disorder care and treatment, which are
integrated facilities that help people get access to acute mental
health care and help people develop plans for long-term recovery.

Other initiatives identified in the Executive Order include:

Working with local law enforcement agencies to
implement pre-arrest diversion programs;

Planning a multi-media education campaign to help
parents, youth, and families communicate about addiction and
the dangers of opioid use;

Launching a Family Task Force comprised of the family
members of people who have died of an overdose, or who are
living with opioid-use disorder;

Piloting and analyzing programs that encourage
disposal of excess opioids to reduce the risk of misuse or
diversion;

Proposing a comprehensive harm reduction strategy
aimed at reducing negative consequences associated with
intravenous drug use.

Use of Data to Inform Processes

MODE Team: Rhode Island has implemented a Multidisciplinary Review
of Drug Overdose Death Evaluation (MODE) Team which combines strategies
of ``rapid response'' with ``community intervention.'' The Team is
modeled after the multidisciplinary review processes for child deaths.
The purpose of the MODE Team is to gain insight into emerging overdose
trends, identify gaps in or opportunities for policy development and
prevention programming and inform the distribution of mini----grants to
Rhode Island communities for prevention efforts. Data sources come from
RIDOH (Medical Examiner reports, Prescription Drug Monitoring Program
(PDMP)), BHDDH (substance abuse and mental health treatment episodes),
Medicaid (healthcare utilization), and RIDOC (incarceration history and
medical records from incarceration). The MODE Team meets quarterly to
review these data. Twenty-five MODE Team recommendations have been
developed, with nine community-based drug overdose prevention mini-
grants distributed thus far.

Surveillance, Response, and Interventions (SRI): This workgroup
made up of staff from DOH and BHDDH review overdose information on a
weekly basis. When overdoses exceed a certain threshold, alerts are
issued to the community, law enforcement, and health providers.

The Community OverDose Engagement (CODE) Program: CODE was
developed in the Spring of 2017. The program calls for the RI
Department of Behavioral Healthcare, Developmental Disabilities &
Hospitals and the RI Department of Health to meet with communities
identified via data tracking whose overdose activity repeatedly exceeds
established thresholds.

Because each community faces unique challenges in tackling the
opioid epidemic, they must tailor their responses accordingly. To be
successful, a collaborative approach is necessary in which all
stakeholders have a significant say in the strategy, significant
responsibility for implementing its components, and significant
accountability for monitoring and demonstrating its effectiveness.
Policies, programs, and initiatives should not be developed and
implemented on the basis of intuition, anecdote, emotion, or political
expediency. Instead, they should be informed by data and evidence. They
should be designed to ensure that we bring an end to this epidemic via
a compassionate approach based in good science and health-based
solutions, rather than a combative approach based in fear, stigma,
shame, and despair.

The goal of CODE is for each community to implement a comprehensive
approach that addresses the problem from all angles: prevention,
overdose reduction, treatment and recovery support. Communities are
encouraged to utilize data-informed and evidence-based practices when
designing and implementing policies and programs.

Results:

This week, RI has released a press release announcing a 10 percent
reduction in overdose rates in 2017. We are cautious to be overly
optimistic in the face of a dynamic epidemic, but can't help but
believe that we are perhaps seeing the results of the implementation of
our strategic plan and complementary initiatives. The battle is far
from over, and we know we need to press on in every aspect of our
efforts, but a glimmer of hope is beginning to be revealed.

Additional ideas for our Federal Partners to consider:

There are numerous opportunities that would help the state's combat
this epidemic and I humbly submit a few recommendations:

An increase in funds is always a tremendous help.
While we appreciate the new grants which have been issued,
increasing the State's Substance Abuse Prevention and Treatment
Block Grant issued through SAMHSA would be the most expeditious
process for distributing funds for new initiatives. Block
grants provide opportunity for states to tailor interventions
to their particular needs. Discretionary grants require
significant administrative time and burden to under-resources
state agencies, and can delay their ability to quickly
distribute new funds. Increasing the Block Grant would allow
states to discuss project needs with their SAMHSA Project
Officer and receive feedback/approval for those needs. Outcomes
on all Block Grant dollars are reported to SAMHSA, therefore
there will be complete transparency on how the funds are used.

Eliminate the prohibition for the use of federal funds
for treatment of incarcerated adults. RI's experience providing
MAT to individuals awaiting trial and for adjudicated
individuals prior to release demonstrates the effectiveness of
a thoughtful approach which can reduce overdose in a vulnerable
population, reduce relapse, encourage recovery and potentially
impact recidivism. State general revenue dollars cannot be
expected to sustain this effort alone. Engaging federal
partners, especially Medicaid, is essential for continuity of
care upon release.

For RI, the continued availability of Medicaid
Expansion to support treatment is essential to our success.

Any federal initiatives include the involvement of the
state agencies. Between the expertise and authority our staffs
have within the substance use disorder system, our agencies can
help to chart the right course.

Treatment for substance use disorders leads to
recovery. Access to the treatment has been advanced by Medicaid
expansion. Continuing to support funding for Medicaid expansion
to single adults with low incomes is essential to helping more
people recover from substance use disorders.

Many individuals living with substance use disorders
do not have access to transportation. Permitting mobile
methadone or buprenorphine provisions would eliminate that
barrier and make treatment more accessible. In addition,
expanding DATA waiver permissions to pharmacists and permitting
the dispensing of methadone from pharmacies would greatly
augment the country's treatment capacity in short order.

Workforce development in the field of substance use
disorders is crucial with a standardized certification program
to license workers across all states. If this were coupled with
a loan forgiveness program, the workforce could grow to the
numbers needed.

With elder opioid addiction on the rise, parity for
Medicare clients would be welcomed by all.

Repealing the Institution for Mental Disease (IMD)
exclusion would allow for meaningful behavioral health care to
those who present with a substance use disorder, truly allowing
every door to be the right door.

Conclusion: I appreciate the opportunity to present testimony
before the Committee. Rhode Island has lost too many lives to drug
overdoses, coming from every community in the state. Our work is
focused on saving lives. I encourage the Committee and Congress to work
with the NGA, NASADAD and ASTHO as well as other partners to leverage
the collective knowledge and expertise of State Alcohol and Drug Agency
Directors and Public Health Departments across the country to help end
this epidemic.

______

[summary statement of rebecca l. boss]
Addiction and overdose are claiming lives, destroying families, and
undermining the quality of life across Rhode Island. For over a decade,
opioid dependence and accidental drug overdose have been growing
problems across the United States, and Rhode Island has been one of the
hardest hit. Over the last 5 years our small state has lost more than
1,200 people to drug overdoses, coming from every community in the
state.

Governor Raimondo established the Governor's Overdose Prevention
and Intervention Task Force naming the Directors of BHDDH and the
Department of Health (DOH) as Co-Chairs. The Task Force included
stakeholders and experts in fields ranging from public health and law
enforcement to healthcare, community-based support services, insurance,
academia, business, government and family members of those who lost
loved ones. The Task Force soon became the hub of all activity in the
fight against the opioid epidemic.

The Task Force created a Strategic Plan for Addiction and Overdose
and recommended numerous strategies within four areas: prevention,
rescue, treatment and recovery. The data-driven plan was created and
soon after, with the help of Brown University a website was created
(www.preventoverdoseri.org) where all efforts are tracked in a public
and transparent fashion.

The work of the Task Force along with the impact of federal
programs, policies and funding, as well as the use of data to inform
processes, Rhode Island is doing a tremendous amount of work and brings
a unique perspective in the fight to end this epidemic.

______

The Chairman. Thank you, Ms. Boss.
Ms. Magermans, welcome.

STATEMENT OF ANDREA MAGERMANS

Ms. Magermans. Thank you. Good morning, Chairman Alexander,
Members of the Committee. Thank you for the opportunity to
testify about the Wisconsin Prescription Drug Monitoring
Program as part of Wisconsin's efforts to combat the opioid
crisis.
My testimony will focus on the creation and operation of
the Wisconsin Enhanced Prescription Drug Monitoring Program,
which was transformed to optimize its utility as a tool to
address this epidemic.
Today I would like to highlight how the Wisconsin ePDMP is
unique as a clinical health care tool, a prescribing practice
assessment tool, an interdisciplinary communication tool, and a
public health tool.
As a clinical health care tool, the Wisconsin ePDMP
includes an enhanced user interface with a patient prescription
history report that was designed to bring the most relevant
information to the immediate attention of the user. This
includes alerts informing providers of concerning prescription
patterns or potential harmful interactions such as an opioid
level over 90 morphine milligram equivalence, concurrent opioid
and benzodiazepine prescriptions, or multiple prescribers or
pharmacies.
Alerts can also be added by prescribers to indicate
patients who are on pain or addiction agreements. The alerts
also notify providers of law enforcement-entered reports.
Graphics on the patient report can help a prescriber
quickly look for overdose risk factors or identify indications
of a patient who obtains controlled substance prescriptions
from multiple providers or who travels long distances to obtain
controlled substance prescriptions. One-click access to a
prescription history report is available through direct
integration with electronic medical records.
Through the direct EMR integration, a prescriber can click
on a button within the patient's medical record to retrieve the
patient's PDMP report within seconds. The prescription history
report that is viewable is the same report that the provider
would see when logging into the Wisconsin ePDMP. That way, a
provider gets the benefits of the analytics and visualizations
that are part of the redesigned patient prescription history
report.
As a prescribing practice assessment tool, the Wisconsin
ePDMP allows prescribers to evaluate their own prescribing
practices in relation to other prescribers in their specialty.
The report shows prescribing volume by drug class and the
average number of doses per prescription for the same drug
classes both in relation to other prescribers of the same
specialty. Those who oversee prescribers are also able to
access prescriber metrics reports through a new and
legislatively required medical coordinator role in the
Wisconsin ePDMP.
As an interdisciplinary communication tool, the Wisconsin
ePDMP includes reports that law enforcement agencies are
required by law to submit in Wisconsin about suspected opioid-
related overdose events, suspected violations of the Controlled
Substances Act involving prescription drugs, and stolen
controlled substance prescription incidents.
The Wisconsin ePDMP then disseminates the reports to
relevant users. This facilitates communication between law
enforcement and health care professionals, and gives health
care professionals a more complete picture of their patients'
controlled substance prescription history to support more
informed prescribing treatment and dispensing decisions.
As a public health tool, statistics are made publicly
available via the Public Statistics Dashboard, which provides
interactive data visualizations about the controlled substance
prescriptions dispensed in Wisconsin, law enforcement reports
submitted to the ePDMP, and the use of the ePDMP by health care
professionals and others.
The efforts that were made to enhance the Wisconsin ePDMP
have already had a large impact. Prior to January 2017, health
care users made approximately 4,800 patient queries per day.
Currently, health care professionals perform anywhere from
25,000 to 35,000 queries per day. With the increased usage of
the Wisconsin ePDMP due to a requirement for prescribers to
review PDMP records before writing controlled substance
prescriptions, the number of prescriptions and doses dispensed
in Wisconsin has decreased.
Even more striking is the coinciding decrease in the number
of patients whose prescription history meets the criteria for
data-driven alerts in the Wisconsin ePDMP system. The total
number of concerning patient history alerts dropped by close to
30 percent between January and September of this year, and
specifically the number of multiple prescriber pharmacy alerts
dropped by nearly 50 percent.
The Wisconsin ePDMP is a successful tool because of the
unique level of involvement of stakeholders and subject matter
experts in the process to develop the enhanced PDMP
application. Because the goal was to meet the users' needs for
efficient, accurate, and actionable data, a concerted effort
was made to include user and stakeholder engagement at every
step of the development of the new system.
The Department of Safety and Professional Services was
recently awarded a Harold Rogers PDMP grant to continue
enhancing the Wisconsin ePDMP, and the grant project will be a
continuation of this collaborative model by working to
implement user-led enhancements.
The development of the Wisconsin ePDMP would not have been
possible without interagency collaboration and grant funding
from federal partners. DSPS is grateful for the federal grant
awards it has received from SAMHSA, the Harold Rogers PDMP
Grant Program, and the CDC, in partnership with the Wisconsin
Department of Health Services.
Thank you again for the opportunity to share this
information with you about the Wisconsin ePDMP's role in
addressing the opioid crisis in Wisconsin, and I will be happy
to answer your questions.
[The prepared statement of Ms. Magermans follows:]

------

Prepared Statement of Andrea Magermans
Chairman Alexander, Ranking Member Murray, and Members of the
Committee, thank you for the opportunity to testify about the Wisconsin
Prescription Drug Monitoring Program as part of Wisconsin's efforts to
address the opioid crisis. I am Andrea Magermans, Managing Director of
the Wisconsin Prescription Drug Monitoring Program (WI PDMP) in the
Wisconsin Department of Safety and Professional Services. My testimony
will focus on the creation and operation of the Wisconsin Enhanced
Prescription Drug Monitoring Program (WI ePDMP) as a clinical
healthcare, public health, and public safety tool. The WI PDMP was
recently transformed to optimize its utility as a tool to address this
epidemic.
Overview of WI PDMP
I have been involved with the WI PDMP since it became operational
in 2013 as a tool to help promote the safe prescribing and dispensing
of opioids and other controlled substance prescription drugs. State
PDMPs are widely recognized as effective tools for combatting the
opioid epidemic by helping prevent prescription drug misuse, abuse, and
diversion. In its most basic form, the WI PDMP is a statewide data base
to which pharmacies and other dispensers submit information about the
controlled substance prescriptions dispensed in the state. The WI PDMP
operates in accordance with Wis. Stat. 961.385 and Wis. Admin. Code
Chapter CSB 4. The Wisconsin Department of Safety and Professional
Services (DSPS) oversees the operation of the WI PDMP in accordance
with the policies established by the Wisconsin Controlled Substances
Board.

The WI PDMP collects approximately 750,000 dispensing records per
month about controlled substance prescriptions in schedules II-V. It
then makes the information available to authorized healthcare
professionals, law enforcement agents, medical examiners, and State
Regulatory Agency employees. De-identified PDMP data is also made
available for public health research purposes. The WI PDMP has been
successfully sharing data with other states, including its border
stares, via the National Association of Boards of Pharmacy's
Prescription Monitoring Interconnect (PMPi) since October of 13. This
means that a WI practitioner who has reason to believe a patient picked
up prescriptions in a different state can request records through the
WI PDMP from the other state's PDMP, and vice versa.

In 2015, although the WI PDMP had only been operational for several
years, the decision was made to enhance and optimize the WI PDMP.
Several factors went into the decision to transform the WI PDMP. State
legislative requirements were going to demand functionalities for law
enforcement and medical coordinator users that did not exist in the
original WI PDMP software and that were not available in any other PDMP
technology solutions. Further, legislation was going to be implemented
requiring prescribers to review patient records in the PDMP prior to
issuing a prescription order for any controlled substance medication.
The previous PDMP system, although an effective tool, was cumbersome to
use and had limited enrollment and utilization. Knowing that the new
legislative requirement would increase the number of users and the
number of daily patient queries dramatically, it was essential that the
enhanced PDMP functionality help overcome the reported barriers to use
of the PDMP system that was in place at the time. The goals of the
development project were therefore to maximize the WI PDMP's clinical
workflow integration, data quality capabilities, and public health and
public safety uses. The result was the WI ePDMP, launched in January
2017.
Key Features of the WI ePDMP
Keeping these goals in mind, the development of the WI ePDMP
redefined the role of the state's PDMP. The WI ePDMP has been
transformed from a prescription tracking tool to a multi-faceted
clinical and communication tool that considers the needs of all of its
potential users. The WI ePDMP is now a robust, sophisticated clinical
healthcare decision support tool, a prescribing practice assessment
tool, an interdisciplinary communication tool, and a public health
tool.
Clinical Healthcare Tool
As a clinical healthcare tool, the goal of the WI ePDMP is to
address controlled substance prescription drug abuse by helping
healthcare professionals evaluate their patients' use of controlled
substance prescription drugs to make more informed prescribing,
treatment, and dispensing decisions. The information available in the
WI ePDMP can also facilitate better coordination of care to patients
seeing multiple professionals and help identify individuals who may be
addicted to prescription drugs and may benefit from referrals to
treatment.

The WI ePDMP goes beyond the basics as a clinical healthcare
decision support tool. The enhanced user interface has a redesigned
patient prescription history report composed of a series of widgets
that are designed to bring the most relevant clinical information in a
patient's controlled substance prescription history to the immediate
attention of the user. This first takes the form of alerts in red at
the top of the report. A patient with no concerning history alerts or
law enforcement-reported incidents would not have any alert buttons at
the top of the report. The alerts inform prescribers of concerning
prescription patterns or potential harmful interactions. Analytics of a
patient's prescription history determine whether a patient has a daily
opioid dose over 90 MME, concurrent opioid and benzodiazepine
prescriptions, early refills, multiple prescribers or pharmacies,
multiple same-day prescription or dispensing events, or long-term
opioid therapy with multiple providers. Alerts can also be added by
prescribers to indicate patients who are on pain or addiction
agreements; the alerts can thereby facilitate communication among
providers and better coordination of care. Further, the alerts are a
mechanism for notifying providers of law enforcement reports of
suspected opioid overdose events, controlled substance violations, and
stolen prescriptions. This is a unique feature of the WI ePDMP that
creates a completely different but clinically relevant data field for
providers to consider when making prescribing and dispensing decisions.
Clicking on any of the large red buttons at the top of the patient
report provides more details about the criteria that triggered the
alert and education about why that information is concerning. All the
possible alerts at the top of a patient's prescription history report
highlight the most relevant and concerning aspects of that patient's
prescription history and give a more complete picture of that patient's
controlled substance history to support more informed prescribing,
treatment, and dispensing decisions.

The use of analytics to provide actionable, meaningful information
to healthcare users of the WI ePDMP system goes beyond the concerning
patient history alerts at the top of the report. On the patient
prescription history report, under any alerts and the patient
demographics, a chart graphically shows a patient's opioid and
benzodiazepine prescriptions over time by indicating the patient's
cumulative morphine milligram equivalent (MME) dosage level as a line
in relation to two benchmarks at 50 and 90 MME. According to the
Centers for Disease Control and Prevention (CDC), risks for motor
vehicle injury, opioid use disorder, and overdose increase at higher
opioid dosages. Patients with 50-99 MME per day have 2x-5x the overdose
risk as someone with 1-19 MME per day. Patients with more than 100 MME
per day have up to 9x the overdose risk as someone with 1-19 MME per
day.\1\ An explanation of the risk factor when a patient's level is
above 50 or 90 is included right on the chart, and shading on the chart
shows the additional risk factor of concurrent benzodiazepine and
opioid prescriptions because, according to the CDC, concurrent use of
an opioid and a benzodiazepine is likely to put a patient at greater
risk for a potentially fatal overdose.\2\ This visualization provides
education about safe prescribing practices and can help a prescriber
quickly look for overdose risk factors prior to prescribing a
controlled substance to a patient.
---------------------------------------------------------------------------
\1\ http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1htm
\2\ http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1htm
---------------------------------------------------------------------------
Each patient report also includes a map widget that shows a visual
depiction of the patient's controlled substance prescription history.
This quick snapshot can help a provider identify indications of a
patient who obtains controlled substance prescriptions from multiple
prescribers or pharmacies or who travels long distances to obtain
controlled substance prescriptions. Clicking on prescriber, dispenser,
and patient icons on the map provides information about the name and
the address of the individual or entity at that location. The map can
therefore also facilitate communication among providers.

Below the widgets in a patient prescription history report is a
table of the patient's controlled substance prescriptions. The table
includes information about the prescription drug, the quantity
dispensed, the refill status, the date prescribed and date dispensed,
the prescriber name and location, the dispenser name and location, the
patient's name and address as they appear on the prescription record,
and the method of payment the patient used when picking up the
prescription. The table can be searched, and it can be exported for
further manipulation.

A lot of collaborative effort went into the design of the
prescription history report to ensure the report met the needs of the
prescribers and others who would be using the report as a clinical
decision making tool. Before the WI ePDMP was launched in January 2017,
prescribers, pharmacists, and other potential WI ePDMP end users
reviewed designs and provided feedback about the redesigned report. The
revamped report is only effective, however, if it is easy to access:
efforts were therefore also made to make the site easier to use. The
number of clicks required to access a patient report was reduced
significantly compared to the previous PDMP system, the registration
process was streamlined, and a responsive design was used so that the
site and the patient reports render nicely on mobile devices. To
further improve access to patient prescription histories, the WI ePDMP
includes a patient panel which shows prescribers a list of patients to
whom they have recently prescribed controlled substances. The list is
searchable and sortable, and, once the desired patient name is found,
it provides one-click access to the patient's prescription history
report.

The ultimate expression of one-click access to a patient's record
in the WI ePDMP is through direct integration with electronic medical
records (EMR). There are currently eight health systems live in WI with
a direct EMR integration with the WI ePDMP, and several other systems
have signed contracts to obtain the service and are testing the
connection. Through the direct EMR-WI ePDMP integration, a prescriber
can click on a button within the patient's medical record in the EMR
platform to retrieve the patient's PDMP report within seconds. The
provider does not have to log out of the EMR and log into the PDMP, nor
does the provider have to enter the name and date of birth of the
patient. What is more, the patient prescription history report that is
returned to the provider is the same report that the provider would see
when logging into the WI ePDMP website and looking up a patient,
including the alerts and visualizations. That way, a prescriber gets
the benefits of the analytics and visualizations that are part of the
redesigned patient prescription history report, regardless of how the
report was accessed. This type of integration was only possible because
Wisconsin developed its own unique, homegrown PDMP platform.
Prescribing Practice Assessment Tool
The only functionality that is currently available to users through
the EMR integration is the review of a patient's prescription history
report. In order to access other functionalities, a user must log into
the WI ePDMP website. Users of the EMR integration are required to be
registered with the WI ePDMP, so they are still able to log into the
website to benefit from the additional functionalities. One of the
functionalities available to prescribers is the review of their own
prescribing practices through the Prescriber Metrics Report. In this
self-assessment tool, prescribers can evaluate their own prescribing
practices in relation to other prescribers in their specialty. The
report includes a table showing all the controlled substance
prescriptions that are attributed to a prescriber's DEA number in order
to help prescribers look for unauthorized use of their DEA number. The
report goes beyond just presenting a simple table, however. Indeed,
located above the table on the report is a series of graphics showing
prescribing volume by drug class and the average number of doses per
prescription for the same drug classes. The values for a given
prescriber are shown in relation to other prescribers in the same
specialty area. The report also shows the number of patients the
prescriber has who meet the criteria for the concerning patient history
alerts or about whom law enforcement agencies have submitted violation,
overdose incident, or stolen prescription reports. Prescribers also
have insight into the total number of controlled substance
prescriptions they have written compared to the number of patient
queries they or their delegates have performed. This gives prescribers
a basic estimated indication of whether they are adhering to the
requirement to review PDMP records before writing controlled substance
prescriptions. For more details about their and their delegates' use of
the PDMP system, prescribers can also access WI ePDMP usage audit
trails when logged into the WI ePDMP website. The knowledge gained by
prescribers through these self-assessment functionalities empowers
prescribers to maintain safe prescribing practices.

Furthermore, Medical Coordinator users of the WI ePDMP can
encourage prescriber accountability by assessing the prescribing
practices of the prescribers they oversee. The WI ePDMP medical
coordinator role was created pursuant to 2015 Wisconsin Act 266, which
requires the WI ePDMP to disclose information to a person who medically
coordinates, directs, supervises, or establishes standard operating
procedures for a practitioner if the person is evaluating the job
performance of the practitioner or is performing quality assessment and
improvement activities, including outcomes evaluation or the
development of clinical guidelines. A new role was developed for these
purposes, and an individual can register to become a Medical
Coordinator user. Medical Coordinators have limited functionality that
allows them to manage lists of the prescribers they oversee and view
the Prescriber Metrics Report for the individual prescribers. Medical
Coordinators do not have access to personally identifiable data, so
they do not see the complete prescribing history of the prescribers.
Rather, they see the metrics about prescribing volume by drug class.
The Medical Coordinator functionality is currently being enhanced to
respond to feedback from the Medical Coordinator users of the system. A
future release of the Medical Coordinator role will allow an easier
comparison among providers that a Medical Coordinator oversees.
Interdisciplinary Communication Tool
Since March 2016, law enforcement agencies have been required to
submit information to the WI PDMP about specific events, and the WI
PDMP has been required to disseminate the information to relevant PDMP
users. The previous PDMP system in Wisconsin did not allow this
functionality, so part of the redesign was to incorporate this
functionality in a meaningful way. The WI ePDMP includes a secure login
for law enforcement employees and allows them to submit reports about
suspected opioid-related overdose events, suspected violations of the
controlled substances act involving prescription drugs, and stolen
controlled substance prescription incidents. The reports are reviewed
by PDMP administrative staff to ensure they are attributed to the
correct patient in the WI PDMP data base and are relevant to the type
of report submitted. The alerts themselves contain a disclaimer stating
that ``Law enforcement agencies are required by Wis. Stat. 961.37 to
submit reports based on `reasonable suspicion' or `belief.' The alert
does not necessarily mean that the individual was arrested, convicted
or is guilty of any violation of criminal law.'' Once the submissions
are processed, they are disseminated to relevant WI ePDMP users in two
ways. Prescribers who have prescribed to the patients in the incidents
receive emails indicating that they have a patient about whom a law
enforcement report has been submitted. They then need to log in and
check their alert tab to view the details of the alert, including the
contact information of the submitting law enforcement agency to request
more information about the incident, if desired. The report is also
displayed as an alert at the top of a patient prescription history
report for healthcare professionals who are accessing the PDMP record
of the patient in question prior to prescribing to, dispensing to, or
treating the patient. The providers therefore have a more complete
picture of the patient's involvement with controlled substances and can
make better-informed prescribing, dispensing, and treatment decisions.
The WI ePDMP thus functions as a communication tool between law
enforcement and healthcare professionals. The reports submitted by law
enforcement are also tracked for public health reporting purposes.
Public Health Tool
Another unique feature of the WI ePDMP is the Public Statistics
Dashboard, which provides interactive data visualizations about the
controlled substance prescriptions dispensed in Wisconsin, the law
enforcement reports submitted to the WI ePDMP, and the use of the WI
ePDMP by healthcare professionals and others. The Public Statistics
Dashboard was developed as part of a Harold Rogers grant project with
the intent of providing statewide and county-level data to the public.
Previously, DSPS created quarterly statistics sheets with basic
dispensing information and a heatmap showing the density of controlled
substance prescriptions dispensed in Wisconsin. The Public Statistics
Dashboard makes similar information available in an interactive format
and includes additional statistics, many of which are available for
specific counties. The WI ePDMP also provides a unique registration and
login functionality for researchers, who can upload information about
the studies they are undertaking and retrieve de-identified data sets.
The WI ePDMP thereby supports public health research on trends in
dispensing of opioids and other prescription controlled substances.
Impact and Effectiveness of the WI ePDMP
Many of the statistics available on the Public Statistics Dashboard
show that the efforts that were made to enhance the WI ePDMP have
already had a large impact. Before the launch of the WI ePDMP in
January 2017, there were approximately 19,000 registered healthcare
users in the previous PDMP system. All users had to re-register in the
WI ePDMP, which is why efforts were made to streamline the registration
process. The process proved easy for many users, some of whom even
reported that they completed registration within a matter of seconds
during a patient encounter. By March 30, 2017, there were over 31,000
registered healthcare users, and there are currently nearly 42,000
registered healthcare users of the WI ePDMP. The increased usage of the
WI ePDMP is also reflected in the number of daily patient queries made
by healthcare professionals. Prior to January 2017, healthcare users
made approximately 4,800 patient queries per day, on average. In
anticipation of the requirement for prescribers to review patient
records in the WI ePDMP that went into effect on April 1, 2017, there
were 17,489 patient queries made by healthcare professionals in 1 day.
By late August 2017, there were as many as 35,000 patient queries made
in a day. Currently, healthcare professionals perform an average of
over 20,000 patient queries per day, with weekday numbers ranging from
25,000 to 35,000 daily patient queries, and weekend numbers remaining
under 5,000 patient queries per day.

Beyond the increased registration and utilization of the WI ePDMP
system, it is possible to see the effects of the WI ePDMP on
prescribing practices. It is important to note that the WI ePDMP is
just one part of the State of Wisconsin's efforts to promote safe
prescribing of controlled substances, so the changes noted cannot
solely be attributed to the WI ePDMP. Nonetheless, the number of opioid
prescriptions and doses dispensed in WI has decreased significantly
from January 2016 through June 2017. Data from the WI ePDMP show that
175,269 fewer opioid prescriptions were dispensed from April 1, 2017 to
June 30, 2017, compared to the first quarter of 2016, a 14.1 percent
decrease. This equates to13 million fewer doses dispensed, a 16.4
percent decrease. Furthermore, there has been a dramatic decrease in
the number of patients whose prescription history meets the criteria
for the data-driven concerning patient history alerts in the WI ePDMP
system. The total number of concerning patient history alerts dropped
by close to 30 percent from January 2017 to September 2017. The
decrease is particularly noticeable for the number of patients with
multiple providers or pharmacies. The analytics for this type of alert
were applied to data from previous years, and a significant change can
be seen in February 2017, right after the launch of the WI ePDMP. Prior
to January 2017, there were consistently over 21,000 alerts per month.
This number dropped below 21,000 in February 2017. Another steady
decrease began in April of 17, when the requirement for prescribers to
review patient records in the WI ePDMP went into effect. The number of
alerts in April 2017 was less than 19,000, and by September 2017, the
number had dropped below 11,000. From January 2017 to September 2017,
the number of multiple prescriber or pharmacy alerts dropped by nearly
50 percent, from 21,088 in January to 10,264 in September. Part of this
change is likely due to the greater number of prescribers accessing the
WI ePDMP because of their requirement to review. Beyond the number of
prescribers who are accessing the WI ePDMP, however, this decrease can
also be considered an indication of the effectiveness of the WI ePDMP
because it is based on a specific report element that is presented back
to end users. End users are alerted to high patient MME, multiple
provider episodes, and opioid and benzodiazepine prescriptions
overlaps, as well as overdose events a patient may have been involved
in. It appears that the analytics going into the alerts and the way the
relevant information is being presented to the end users is changing
prescribing behaviors.
Development Process
Beyond the unique key features of the WI ePDMP, the WI ePDMP is
also unique because of the level of involvement of stakeholders and
subject matter experts in the process to develop the enhanced PDMP
application. The project goal was not only to address shortcomings of
previous system, but also to reimagine the role of the system in
addressing opioid crisis. The strong support for the project came from
agreement among stakeholders, legislators, and administration that the
epidemic required a strong response. Because the goal was to meet the
users' needs for efficient, accurate, and actionable data, a concerted
effort was made to include user and stakeholder engagement at every
step of the process. This meant that there was subject matter expert
and user review and involvement during the scoping, designing,
development, and testing of the new application. DSPS collaborated with
professional associations to identify subject matter experts and
potential users who were regularly involved in continual feedback
loops. The development process was iterative, with 2-week development
cycles. Users would review designs and provide feedback; the feedback
would then be implemented in the development of the application. The
iterative improvement process continued throughout 2016 before
launching the new PDMP system and still continues to this day as
informed by feedback from actual users in the field. One example of the
impact of continued feedback loops on the functionality of the WI ePDMP
system decreased the number of clicks to get to get to a patient's
record by suggesting that the cursor on a search page be defaulted to
the first name field. The suggestion was made by multiple users, and
the change was subsequently implemented. This small change not only
improved the user experience with the WI ePDMP but also showed the end
users that they are an important part of the development and success of
the system. The increased user buy-in has given users a sense of pride
and ownership, which has led in part to the success of the WI ePDMP.
Prescribers in particular are beginning to see checking the PDMP as
something more than just a requirement; they are recognizing it as a
useful clinical tool and making suggestions to continue to make it
better. DSPS was recently awarded a Harold Rogers PDMP grant to
continue enhancing the WI ePDMP, and the grant project will be a
continuation of this collaborative model by working to implement user-
led enhancements.

The development of the WI ePDMP would not have been possible
without interagency collaboration and grant funding from federal
partners. DSPS is appreciative of the opportunities that have been
afforded to it through federal grant awards from the Substance Abuse
and Mental Health Services Administration (SAMHSA), the Office of
Justice Programs in the Bureau of Justice Assistance at the U.S.
Department of Justice, and the CDC. The SAMHSA grant allowed DSPS to
implement a previous PDMP-EMR integration and work toward the current
direct EMR-PDMP integration model. DSPS received two Harold Rogers PDMP
Enhancement Grants in 2014 and 2015, first to build the Public
Statistics Dashboard, which was originally envisioned as a stand-alone
website along side the previous PDMP system, and later to build the WI
ePDMP. Grant funding from a CDC Drug Overdose Prevention Grant in
partnership with the Wisconsin Department of Health Services further
supported the development of the WI ePDMP.
Lessons Learned/Recommendations
The involvement of PDMP administrators, subject matter experts, and
potential WI ePDMP users at every step of the development process was
critical to the success of the WI ePDMP. The administrators of other
State PDMPs have shown a keen interest in learning about and from the
experience of developing the WI ePDMP, not only from a technology
perspective but also from a project methodology perspective.
Collaboration among PDMP administrators should be encouraged by
providing opportunities for PDMP administrators to meet, discuss
challenges, and learn from each other's experiences. It is difficult to
know the types of functionalities to strive for without first
understanding the realm of possibilities by knowing about what is going
on in other states. The sharing of actual PDMP technology could also be
facilitated through the encouragement of open-source PDMP software
solutions. The WI ePDMP has also been successful because of the way it
redefined the role of the State PDMP and took bold steps to transform
the PDMP system to meet the needs of those who use it. This type of
innovation should be encouraged but is sometimes stifled because of a
lack of awareness of possibilities. In general, states are very
appreciative of grant funding opportunities to improve their PDMP;
however, they may be tempted to defer to the use of grant dollars for
known solutions or vendors if they do not have the drive, awareness,
and support to innovate. In the case of the WI ePDMP, innovation led to
a successful home-grown solution that is tailored to the situation in
WI. Furthermore, the involvement of PDMP administrators at every step
of the development process proved invaluable in WI, but this
involvement is not always the case, especially when funding involving a
state's PDMP is awarded to an agency that does not house the state's
PDMP. Wisconsin has been fortunate to be able to collaborate closely
with the Wisconsin Department of Health Services to enhance the WI
ePDMP as part of a CDC grant. Funding opportunities that involve a
state's PDMP should require that PDMP admins be directly involved in
the projects.
Conclusion
Thank you again, Chairman Alexander, Ranking Member Murray, and
Members of the Committee, for the opportunity to share this information
with you about the WI ePDMP's role in addressing the opioid crisis in
WI. The transformation of the WI ePDMP into a robust clinical decision
support tool has been well received by the medical community in WI. The
success of the WI ePDMP as a tool to help combat the opioid abuse
epidemic would not have been possible without the involvement of
stakeholders and users throughout the development process. The
collaborative nature of the WI ePDMP development project, including the
involvement of PDMP administrative staff, interagency support, and
federal grant funding, has led to impressive results and has set the
stage for continued enhancements to the WI ePDMP based on user feedback
to ensure that it remains an effective tool in the State of Wisconsin's
efforts to combat the opioid crisis.

______

[summary statement of andrea magermans]
Chairman Alexander, Ranking Member Murray, and Members of the
Committee, thank you for the opportunity to testify about one part of
Wisconsin's efforts to address the opioid crisis. My testimony will
focus on the creation of the Wisconsin Enhanced Prescription Drug
Monitoring Program (WI ePDMP) to optimize its utility as a clinical
healthcare, public health, and public safety tool. The development of
the WI ePDMP redefined the role of the PDMP: it is now a robust
clinical healthcare decision support tool, a prescribing practice
assessment tool, an interdisciplinary communication tool, and a public
health tool.

As a clinical healthcare tool, the WI ePDMP includes an enhanced
user interface and a redesigned patient prescription history report
that is designed to bring the most relevant clinical information in a
patient's controlled substance prescription history to the immediate
attention of healthcare users of the WI ePDMP.

As a prescribing practice assessment tool, the WI ePDMP allows
prescribers to evaluate their own prescribing practices in relation to
other prescribers in their specialty through the Prescriber Metrics
Report. The knowledge gained by prescribers through these self-
assessment functionalities empowers them to maintain safe prescribing
practices. Those who oversee prescribers are also able to access
Prescriber Metrics Reports through a new Medical Coordinator role in
the WI ePDMP.

As an interdisciplinary communication tool, the WI ePDMP includes
reports submitted by law enforcement about suspected opioid-related
overdose events, suspected violations of the controlled substances act
involving prescription drugs, and stolen controlled substance
prescription incidents and disseminates the reports to relevant WI
ePDMP users. It facilitates communication between law enforcement and
healthcare professionals and gives healthcare professionals a more
complete picture of their patients' controlled substance history to
support more informed prescribing, treatment, and dispensing decisions.

As a public health tool, statistics are made publicly available via
the Public Statistics Dashboard, which provides interactive data
visualizations about the controlled substance prescriptions dispensed
in Wisconsin, the law enforcement reports submitted to the WI ePDMP,
and the use of the WI ePDMP by healthcare professionals and others.

Beyond these key features, the WI ePDMP is unique because of the
level of involvement of stakeholders and subject matter experts in the
process to develop the enhanced PDMP application. Because the goal was
to meet the users' needs for efficient, accurate, and actionable data,
a concerted effort was made to include user and stakeholder engagement
at every step of the process.

______

The Chairman. Thank you, Ms. Magermans.
Secretary Tilley, welcome.

STATEMENT OF HON. JOHN C. TILLEY

Secretary Tilley. Thank you, Chairman, for your welcome
again. Thank you for that. I want to say what an honor it is to
be here, and also to say to you this is heavy stuff. But if I
may just take a moment, Chairman, and say that growing up in
West Kentucky, very near where Senator Paul--and thank you for
that nice introduction, Senator. I've seen your passion
firsthand for reform, and your intellect on these issues is
unquestioned. But he knows how closely we live to Tennessee,
and also how closely we are aligned with the national media.
Many of my family members back in the day from Kentucky
went to the polls trying to vote for the Chairman, Lamar
Alexander, because of that. Also we were readers of your little
plaid book, everything you need to know. It's kind of like
Kinder contained in this book. It's certainly a Bible for us,
and thank you for that. If you think that's pain, it certainly
is.
The Chairman. You may be the best witness we've had in
years.
[Laughter.]
Secretary Tilley. Thank you. Goodnight. I've had a great
run.
[Laughter.]
Secretary Tilley. Again, it is such heavy stuff. During the
course of debates we had over 3 years to come to what became
known as the heroin bill in Kentucky, Senator, as you remember,
we kept the North Star with us in Kentucky, a young man by the
name of Wes Jenkins, who at 12 years old was part of a Little
League World Series championship team from Louisville. Not
often do American teams win the Little League World Series, and
certainly not from Kentucky, a smaller state like ours.
But, Senator, you remember that day. I remember the last
pitch and seeing them pile on one another, beating Japan that
day. They were not favored to win.
Ten years later, Wes Jenkins died of an overdose, the same
story. He went for oral surgery when he was playing college
baseball, and three stints in rehab later he overdosed the day
he stepped out of that third rehab.
We never forgot Wes Jenkins, him being also the nephew of
one of my colleagues in the House and Senate.
We worked together, put down any partisanship, no room for
that, locked arms and got some good things done. I think
without the help of the Federal Government, we could not have
done what we've done in Kentucky.
Let me start with our Department of Corrections response.
Make no mistake, this opioid pandemic--it's no longer an
epidemic--has had an amazing, incredible negative impact on our
criminal justice system. It's a public health nightmare being
handled in courtrooms and jails and prisons, and that is part
of the problem. We don't have time to address all that today.
One of the things we're most proud of is the fact that
we've increased treatment by 1,100 percent thanks to some of
the resources you've given us. The ROI on treatment behind our
walls is about almost five dollars. It cuts recidivism, cuts
rates of mental illness. We track these offenders once they
leave our prisons and jails. In terms of getting to that ROI,
that return on investment, it's money well spent.
We also have something that's been really chronicled
nationally, a pilot program using naltrexone or vivitrol. We
give a shot 30 days before release, we give a shot the day of
release, and give a shot 30 days after, with the injection
being every 28 days or 30 days to battle this incredible
chronic brain disease, and we have seen great early results
from that program. The return on investment, even with the
expense of that drug, is very high. The return is very high.
Again, we received a lot of attention for that and would like
to expand that. We're doing that as we speak.
We're also proud of our coordination with law enforcement
and public health. The Cabinet for Health and Family Services,
that is unprecedented now in our state. The CDC in their
recommendations and their money has allowed us to track
overdoses in ways with law enforcement we never have.
We've also been able to collaborate for training protocols
for physicians and nurses and dentists on many prescribing
practices that we know are very critical to this problem.
We've also been able to up the distribution of naloxone in
ways that have never been seen, and I would submit to you that
we need over-the-counter naloxone. The only use we have for
that is to battle back and reverse these overdoses, and so we
do that.
My good friend Rebecca, we've worked together for years
now, and we are using now the Rhode Island model in Kentucky.
I'm really proud to report--and what I mean by that is the one
she spoke of using peer specialists in the emergency
departments, and also using bridge clinics at the same time.
It's an ambitious goal to reach, but we've done that. In the
first week we used it at the University of Louisville just
recently, Senator, we had the first five people to walk in and
overdose. By the way, we had 13,000 overdoses in Kentucky
emergency rooms alone in 2016. But the first five who walked
in, four entered treatment. That's a great sign, and that
actually follows the national trend line from Rhode Island.
Eighty percent will do that.
Before that model, we lost 13,000 opportunities to link
somebody to treatment who came in with an overdose. We lost
1,404 Kentuckians. As you know, the numbers are staggering. In
the last 10 years, or at least between 2006 and 2016, we lost
471,000 Americans. That can be lost.
Again, I see my time is up. There is too much to cover. I
hope that the questions come fast to us because we would love
to cover some of the unique things and innovative ways we're
attacking it in Kentucky.
Thank you, Chairman.
[The prepared statement of Secretary Tilley follows:]

------

Prepared Statement of John Tilley
Kentucky's Crisis
2016 proved to be a deadly year for the citizens of the
Commonwealth of Kentucky, who saw 1,404 of their family members,
friends, and neighbors die from drug overdoses. Since 2012, drug
overdoses have accounted for more accidental Kentucky deaths than motor
vehicle crashes. The leading culprit, fentanyl, a potent synthetic
opioid, was detected in 47 percent of overdose deaths, up from 34
percent in 2015. According to the Kentucky State Police, there was a
6,000 percent increase in laboratory samples submitted to the Central
Forensic Laboratory testing positive for fentanyl from 2010 to 2016.
Last year, in addition to fentanyl, the Kentucky State Police reported
samples from 10 different counties testing positive for carfentanil, a
fentanyl derivative that is 100 times more potent than fentanyl itself.
Fentanyl continues to engulf Kentucky as the Kentucky State Police
report that the number of submissions testing positive for fentanyl in
the first two quarters of 2017 has already exceeded the 2016 total. The
2017 samples also included several potent fentanyl derivatives such as
cyclopentylfentanyl, acetylfentanyl, butyrylfentanyl, acrylfentanyl,
furanylfentanyl, and carfentanil. According to Appalachia HIDTA's 2018
Threat Assessment, Kentucky remains particularly vulnerable to drug
trafficking organizations because of its central geographical location
and many interstate highways.

In addition to increased rates of substance use disorders and
overdose deaths, the opioid epidemic has also brought the threat of
blood borne pathogens such as viral hepatitis and human
immunodeficiency virus (HIV). According to the Centers for Disease
Control and Prevention, 54 of the top 220 counties most vulnerable to a
rapid outbreak of HIV are located in Kentucky. In response to the
devastating HIV outbreak in nearby Austin, Indiana in 2014, Kentucky
became the first southern state to authorize the creation of syringe
exchange programs, which are designed to reduce the incidence of needle
sharing and prevent the spread viral hepatitis and HIV. There are
currently 41 Harm Reduction Syringe Exchange Programs (HRSEPs)
operating across the Commonwealth since the General Assembly granted
county officials the power to approve such programs. Aside from HIV,
forms of viral hepatitis--such as hepatitis C--also pose a large threat
to the residents of Kentucky. From 2008 to 2015, Kentucky had the
highest rate of acute hepatitis C infections in the United States.
Department of Corrections Response
The Kentucky Department of Corrections remains the single largest
treatment provider in the Commonwealth. In 2004, the department had 475
substance abuse treatment slots available. Today, it has 5,901
treatment slots, representing a 1,100 percent increase since 2004. The
substance abuse treatment programs utilize evidence-based cognitive
behavioral therapy and therapeutic community models. According to a
recent study by University of Kentucky professors, the department's
treatment programs resulted in a strong return on investment--$4.29 of
cost avoidance for every $1 spent in fiscal year 2015. During the 12
months following release, 70 percent of participants were not re-
incarcerated, 85 percent maintained housing, and 68 percent were
employed at least part-time. The study participants also reported
decreased illicit drug use, decreased feelings of serious depression
and anxiety, and decreased instances of suicidal ideation.

In 2015, the Department of Corrections began a pilot project aimed
at reducing fatal overdoses among inmates released on parole. The
department uses a validated risk and needs assessment to target those
inmates most vulnerable to overdoses and offer them the chance to
voluntarily receive injections of naltrexone, a long-acting opioid
receptor antagonist, before they leave prison. Within 24 hours of being
paroled, participating inmates meet with social service clinicians at
their local Probation and Parole offices for assistance determining
health care coverage eligibility and setting up an appointment for the
inmate's next naltrexone injection. The initial results from the pilot
project have been so promising that representatives from five other
states, tribal authorities from Montana, and the U.S. Virgin Islands
have observed the program.
Coordination between Public Health and Law Enforcement in Kentucky
The opioid epidemic has demanded intense collaboration between the
Kentucky Department of Public Health and the Kentucky Office of Drug
Control Policy. Recently, the Department of Public Health contracted
with the Kentucky Injury Prevention and Research Center (KIPRC) to
provide data analysis and technical support in joint endeavors with the
Office of Drug Control Policy. Over the last few years, KIPRC and the
Office Drug Control Policy have utilized grant funding from the Centers
from Disease Control and Prevention to create the Commonwealth's drug
overdose surveillance program. The drug overdose surveillance program
compiles data on drug overdose deaths from county coroners, physicians,
and the Office of the State Medical Examiner into one data set, which
is used to compile a detailed annual overdose death report. In addition
to the drug overdose surveillance program, the partnership between
KIPRC and the Kentucky Office of Drug Control Policy has also led to
the development of training protocols for physicians, nurses, and
dentists on appropriate opioid prescribing methods. Thousands of
Kentucky law enforcement officers have been trained on the proper
treatment of opioid overdoses and the use of emergency naloxone kits
thanks to the partnership as well.
21st Century Cures Act Programming
The Office of Drug Control Policy worked closely with
representatives from the Cabinet for Health and Family Services to
develop a comprehensive strategy for using funds from the 21st Century
Cures Act. The Kentucky Opioid Response Effort (KORE) is a
multidisciplinary team established to administer the funds granted to
the Commonwealth from the Cures Act to bolster evidence-based treatment
interventions aimed at reducing the impact and prevalence of opioid use
disorder among non-fatal drug overdose survivors, pregnant and
parenting women, and incarcerated individuals.

Initiatives aimed at survivors of non-fatal overdoses include the
creation of specialized medication-assisted treatment bridge clinic
programs and the placement of peer recovery specialists in emergency
departments. The specialized bridge clinics initiate a medication-
assisted treatment protocol with overdose victims while they are still
in hospital in order to stabilize them long enough to obtain treatment
in the community. KORE funded one of the first bridge clinics at the
University of Louisville's emergency department in partnership with
Centerstone, a community mental health center earlier this month. On
the first day of operation, peer recovery coaches deployed to the
hospital's emergency department contacted five individuals treated for
opioid overdoses. Four of the five opioid overdose survivors contacted
by peer recovery coaches opted for immediate entry into treatment.

The peer recovery specialist initiative, which was modeled after
Rhode Island's Anchor ED program, incentivizes Kentucky hospitals to
contract with certified peer recovery specialists who could counsel
recent drug overdose survivors while they are still in the emergency
department and help them enroll in a treatment program if the survivor
chooses treatment in that instance. Some additional funds are being
used to distribute naloxone at community awareness events, emergency
departments, and syringe exchange programs

The initiative aimed at pregnant and parenting women will create an
integrated continuum of care model, aimed at synchronizing obstetrics
care, primary care, medication-assisted treatment provider care, and
case management. Once the model is perfected, a training program will
be developed and offered to healthcare and treatment providers.

Finally, part of the 21st Century Cures Act funding will be used to
create a targeted employment pilot program for state and county inmates
reentering society with a history of opioid use disorder. The program
will hire employment specialists to assist former inmates in finding
and maintaining employment in Northern and Eastern Kentucky, which are
two regions that have been most affected by the opioid epidemic.
______

[Summary Statement of John Tilley]
Kentucky's Crisis
In 2016, Kentucky lost 1,404 citizens to drug
overdoses.

Since 2012, drug overdose deaths have accounted for
more accidental Kentucky deaths than motor vehicle crashes.

Medical examiners detected fentanyl in 47 percent of
Kentucky overdose victims in 2016, up from 34 percent in 2015.

The Kentucky State Police Central Forensic Laboratory
has also seen an increase in the detection of potent fentanyl
derivatives such as carfentanil and cyclopentylfentanyl.

Kentucky is at an elevated risk of an outbreak of
blood borne pathogens such as HIV and hepatitis C due to unsafe
injection practices among those suffering from opioid use
disorder.

According to the Centers for Disease Control and
Prevention, Kentucky has 54 of the 220 counties most vulnerable
to a rapid outbreak of HIV.
Department of Corrections Response
The Kentucky Department of Corrections has increased
substance abuse treatment slots from 475 in 2004 to 5,901 in
2017, a 1,100 percent increase in treatment capacity.

According to a recent study, the department's
substance abuse treatment program resulted in a $4.29 cost
avoidance for every dollar spent on the program.

In 2015, the department created a pilot program
designed to reduce fatal overdoses among inmates released on
parole by providing them the opportunity to receive naltrexone
injections prior to release. Preliminary results from the pilot
have been so promising, that representatives from five other
states, tribal authorities from Montana, and delegates from the
U.S. Virgin Islands have observed the program.
Coordination between Public Health and Law Enforcement in Kentucky
The Kentucky Department of Public Health and the
Kentucky Office of Drug Control Policy have collaborated to
create Kentucky's drug overdose surveillance system using grant
funding from the Center for Disease Control and Prevention.

The collaboration has also resulted in the development
of training protocols for physicians, nurses, and dentists on
appropriate opioid prescribing practices.

Thousands of Kentucky law enforcement officers have
been trained to treat opioid overdoses with emergency naloxone
kits thanks to the collaboration as well.
21st Century Cures Act Programming
Pilot sites for the creation of treatment bridge
clinics and the placement of certified peer recovery
specialists in emergency departments have begun to operate.

A targeted employment pilot program aimed at state
county inmates who have a history of opioid use disorder is
being develop for sites in Northern and Eastern Kentucky.

Additional funds are being used to hold community
training sessions and distribute emergency naloxone kits.

______

The Chairman. Thank you very much, Secretary Tilley, and
thanks for bringing the little plaid book with you.
Secretary Tilley. I hope it worked. Thank you.
The Chairman. I'll say to the Senators who have come in,
we've had very interesting testimony from four witnesses who
are on the front lines of states dealing with opioids, and now
we'll go to a 5-minute round of questions. We thank you for the
testimony.
We'll begin with Senator Young.
Senator Young. Well, thank you, Chairman. That's a good way
for me to step off your lead in there, because Indiana has
indeed been on the front lines of this opioid crisis, and I
thank all of our witnesses for their testimony and expertise in
this area.
I visited with a number of local sheriffs throughout
Indiana. I used to represent, in the House of Representatives,
Indiana's 9th Congressional District, which included Scott
County, Indiana. That is where Austin, Indiana is located that
gave national attention to that county, not in the best way,
but they fought their way back and continue to.
Many local sheriffs throughout the state have a strong
suspicion that their inmates not only have opioid addiction
challenges but also have HIV, Hep C, or TB. But they're left
with this moral dilemma. You see, they have a limited budget to
take care of their criminal justice matters each year, but they
also are supposed to attend to the health care of those
individuals. If they test these inmates and identify that they
have Hep C, that they have TB and so forth, then that could
conceivably and very realistically deplete the entire law
enforcement budget they have for a year. These public servants
are on the horns of a human rights dilemma.
Director Boss, you've made some suggestions in your
testimony about how we can better treat, as a Nation,
incarcerated individuals. You also touched on how we can better
treat individuals awaiting trial. Would you kindly elaborate on
this issue generally and some of the suggestions you have for
us?
Ms. Boss. I would, and thank you for that opportunity.
Individuals awaiting trial who are not yet adjudicated are
often some of the most complex individuals that we see because
they're coming from the street to a center that will house them
with the multiple medical issues that you identify, including
addiction and in the stages usually of withdrawal when they are
opioid addicted.
One of the things we find most helpful is really addressing
that health care need. An addiction is a disease, and addiction
treatment is a health care issue. Providing medication, as you
would for any other health care issue, in alleviating those
withdrawal symptoms and providing stability for the individual
in their addiction has been very successful.
What we see is individuals sometimes coming in already on
medication-assisted treatment. Previously we would withdraw
those individuals and put them into withdrawal and then,
depending upon the results of their trial, would be released
back into the street, now in withdrawal, now sick and looking
to use again and very vulnerable because their tolerance level
has decreased. The number of overdoses in that population was
significant.
Providing them continued medication or, better yet,
initiating the medication for individuals who needed it but
didn't access it in the community provides that linkage after
that brief period of incarceration to the treatment that's
needed in the community, and the follow-up rates have been
pretty successful. Seventy-five percent post-incarceration
without perhaps the requirement of the criminal justice system
that they do so is pretty remarkable, including the decrease in
the overdose in that population that we have seen is incredible
given the decreased tolerance that they had before, no longer
that because they're on medication that has stabilized them,
and a connection to treatment in the community, with the
opportunity now for recovery. Perhaps that criminal justice
intervention gave them that opportunity for recovery that they
didn't capitalize on in the community.
Senator Young. Well, thank you.
Secretary Tilley, you're our southern neighbor, and you, no
doubt, are experiencing very similar situations as we are. Can
you speak a bit about any programs you have in place to get
treatment to these incarcerated adults or those who are
awaiting trial, get them into treatment in a better spot?
Secretary Tilley. I think, first of all, I'm not proud to
report that we've had to ramp up treatment in our prisons by
that 1,100 percent mark. But what we've done to do that is
we've collaborated and partnered with our community mental
health centers to use intensive outpatient treatment upon
release, because that handoff is often, again--it is the most
critical time. We've done that.
We are also, as I mentioned--the program we have that uses
naltrexone, I didn't have a chance to expand on that. It's not
just about the medically assisted component. There is also the
holistic component of therapy and a social service clinician on
the day that inmate leaves the prison, to lead them to
resources in whatever community they're returning to; that's a
really critical piece. We've gotten, again, great early numbers
on that. We're trying to expand that. It is an expensive
program, but it's certainly less expensive than the $24,000-a-
year cost of incarceration and all that comes with that--
societal strain, family strain, et cetera.
Many other programs along those lines. The treatment of
providers is coming in so fast to our state that that's one of
the challenges, to make certain that we get them running as
quickly as possible and at the same time not allow fly by-night
providers. Only 1 percent of treatment right now is evidence
based. That's a challenge for us.
In the interest of time, the last program I might mention
again to link people to treatment is this--we have a treatment
hotline, but is this peer specialist bridge clinic, because
those folks are going to end up in jails and prisons. Clearly,
it happens more times than not. To link them to treatment
before that criminal justice intervention is critical. Again,
returns on investment and as a policy win and a public health
win.
Senator Young. Thank you, Mr. Secretary.
A quick observation, Chairman, is that as we consider
funding at the federal, state, and local level to address all
these things, we're going to have to consider the costs of not
doing something, the economic costs, and cost in social
services and so forth. We're going to have to constantly keep
that in mind, the cost of doing nothing or not doing enough.
Thank you.
The Chairman. Thank you very much, Senator Young.
We have a lot of Senators here today, so I'm going to try
to stick pretty close to the 5-minute limit so everyone will
have a chance to ask questions.
Senator Kaine.
Senator Kaine. Thank you, Mr. Chair.
Dr. Abubaker, my questions are mostly going to be directed
to you. Talk about the over-prescription problem and the work
that you're doing with prescribers. Many of us have worked on
bills, some of which were included as part of the Comprehensive
Addiction Recovery Act, to set up prescription guidelines
around the co-prescription of naloxone, for example. On the
Armed Services Committee, I've worked with colleagues there to
deal with over-prescription issues within the VA and the DOD
hospital system.
But talk about your own work with especially folks in
dentistry and your students and what more we can do to curb
this over-prescription problem we have in the country.
Dr. Abubaker. Thank you, Senator Kaine. I'll just step
backward and relate it to prescription or over-prescription.
I went through my dental school education, a good dental
school in Pittsburgh, and went through my residency, and the
emphasis on prescription or pain management was minimal, not
only in dental school and residencies and dentistry but in
medicine as well. Pain management is at the core of it, and
what we train is really to write a prescription and walk away
from the patient.
That model ends up over-prescribing. There are patients who
may need only two tablets, and there are patients who may need
50 tablets. We have not had that kind of way of thinking.
Prescription writing was a thoughtless, seamless process on the
part of both physician and dentist, and that goes back to the
lack of knowledge about pain management, acute pain management.
I'm specifically talking about acute pain management.
As a result, we standardized that you go to the oral
surgeon for wisdom teeth, probably 20 tablets of Vicodin. You
go to the orthopedic surgeon, they have a number, and
neurosurgeons have numbers, and it's not standardized to the
individual situation or an individual patient.
Senator Kaine. The numbers themselves may not be science-or
evidence-based at all.
Dr. Abubaker. Absolutely. There is no science to it.
Clearly, if there is a science, Patient A is not the same as
Patient B, whatever way you look at it. As a result, that
standardized number that we put in a prescription, it's not a
scientific one. As a result, we end up over-prescribing for the
most part.
We looked at pain management as 100 percent prescription.
We looked at prescriptions for the worst pain. We looked at
prescriptions as the only treatment possible. We know now that
for some other modalities, including non-pharmacological pain
management, that it's good for some individuals but may not be
good for others.
The standardization of treatment is the key for this, and I
think going back to the education factor--my business is the
education business for the last 27 years--we have to go back to
the basics. No. 1, pain management, the scientific basis of
pain, the lack of standardization or the lack of evidence base,
and going back to the risk associated with medication.
I mentioned to you earlier that in some states now the
regulation for prescribing includes mandatory discussion with
the patient about the risks, possible complications, and how to
dispense with the extra medication. Some people got 20 tablets,
took 3 tablets, it sat in the cabinet and the grandchild
grabbed it.
The fundamental issues; we have to go back to the basics
both in medical education, dental education, nursing education
to be able to address the foundation, the root of the problem.
Senator Kaine. You testified powerfully that this war on
opioids really needs to be a war on addiction, and you have a
clinic, the Motivate Clinic, which is designed really to go
after the addiction problem. Tell us a little bit about that.
Dr. Abubaker. The Motivate Clinic just started actually
this year, and part of our legislative and our state effort to
combat opioids and addiction in general. But the story used to
be in an emergency room, when you come in with an overdose of
any drug, you're treated for the overdose, admitted to the ICU,
and when you live, they put you back on the street. God knows,
maybe a week later, a month later, you come back with the same.
There is no organized, systematic way of referring this patient
to a specific treatment.
VCU Medical Center developed a process. Now, when a patient
comes in with an overdose, after treatment for the overdose,
hopefully they survive the overdose, they automatically are
referred to a clinic for follow-up and additional treatment
down the line in the long term.
Senator Kaine. This is a little bit like what Secretary
Tilley was talking about in Louisville, the example that he was
using.
One last question, quickly. You also do work at VCU to help
addicted pregnant moms break their addiction. Talk a little bit
about that.
Dr. Abubaker. Senator Kaine, clearly, the director of the
Motivate Clinic is, by training, an Ob/Gyn.
Senator Kaine. I see.
Dr. Abubaker. He came from that side. He's a professional
on that side, but he came into the side of addiction through
pregnant women and children born addicted. That's his passion.
That's his practice. There is a lot of it going on in our
medical center.
Senator Kaine. Great. Thank you for being here today.
Dr. Abubaker. Thank you. My pleasure.
The Chairman. Thank you, Senator Kaine.
The Ranking Member, Senator Murray, is here.
Senator Murray, I invited Senator Kaine to make opening
remarks because you had another commitment. But if you have
opening remarks you'd like to make, you're certainly welcome to
make them.
Senator Murray. Mr. Chairman, I just would like to thank
you for having this hearing, and I won't delay. We have lots of
folks who want to ask questions, so I'll submit it for the
record. Again, thanks very much.

[Opening Statement of Senator Murray Submitted for the Record]

Senator Murray. Thank you, Chairman Alexander, thank you for your
continued commitment to hold these bipartisan hearings on the opioid
crisis.
Needless to say, there's a whole lot going on right now in the U.S.
Senate, and frankly, there's been a lot of strong disagreement and at
times, very heated discussions around several issues.
The so-called tax ``reform'' package being jammed through today,
with yet another attack on families' health care, we have end of the
year spending deadlines--you name it.
But I hope we can all agree that the opioid crisis is an issue
that, no matter what else is going on, cannot afford further inaction,
as many have heard me say on this Committee.
For the countless patients and families suffering from this
epidemic, there is no tomorrow and there is no next time.
It is absolutely critical that we make progress to address this
truly devastating public health crisis--and that we do so in a
bipartisan manner.
I am pleased that we are joined today by a diverse group of
witnesses, providers, public safety officials, and state health
officials, who are on the front lines fighting this epidemic--and who
can speak to what is going down on the ground and what more we in
Congress can do to help them address this crisis.
I am also interested in learning more about ways we can help bring
communities together to prevent and combat addiction, and how that
compares with what I am hearing back in my home State of Washington.
Because, like everyone here, the opioid crisis is something I hear
about every weekend I go back home.
I've visited with countless communities that have just been
devastated by addiction, this epidemic does not discriminate, it can
reach anyone, and it can reach anywhere. I've listened to doctors who
are treating skyrocketing numbers of babies born addicted to opioids--
parents who have lost sons and daughters, children who have lost moms
and dads, to an overdose--and veterans with chronic pain who also
struggle, each and every day, with addiction.
The list, unfortunately, goes on and on. I will repeat this every
time I can, this epidemic is not somebody else's problem. It's all of
ours.
Again, that's why I am very glad we have the opportunity today to
discuss this further and to hear from those closest to the ground about
what they are seeing.
Now, right off the bat, it's clear to me there are steps we can
take right now that would make a tremendous difference in this fight.
We have seen increased public awareness around this crisis, we are
learning more about addiction each day, but we continue to lack the
increased investments and response needed from this Administration--
that would truly help states and communities address this complex
challenge.
As we all know, late last month, President Trump finally issued a
memorandum to the Department of Health and Human Services and other
agencies on the opioid crisis.
I had hoped this announcement would bring about a much-needed
change of course, and that President Trump would finally commit to
supporting the substantial new investments that states, communities,
and hospitals are making very clear they need to make progress on this
crisis.
Unfortunately, President Trump's attempt at appearing to take
action did nothing to give states and communities the resources they so
desperately need, and in fact suggested that this problem could be
addressed by using funding for other public health priorities, which
underestimates the needs in all these areas. This was deeply
disappointing.
Unfortunately, it represents a pattern of tough talk, no action
that we've seen time and again from this Administration. And just to
further underscore how inadequate this Administration's response to the
opioid crisis has been--earlier this month, the White House's own
Council of Economic Advisors released a report estimating the economic
cost of the opioid crisis to be at over $500 billion dollars, just for
2015.
That is six times larger than the most recently estimated economic
cost of the opioid epidemic. So we desperately need this Administration
to be a partner in fighting this epidemic.
But unfortunately what we continue to see is simply not enough.
Congress has taken some steps, thanks to our bipartisan efforts on this
Committee, to address the opioid crisis.
Like everyone here, I am proud of our work to pass the 21st Century
Cures Act, which included nearly $1 billion for states to address the
opioid crisis through: prevention, treatment, and recovery efforts.
CARA, the Comprehensive Addiction and Recovery Act, which supports
specific outreach for veterans and pregnant and postpartum women
suffering from addiction, and expands access to medication assisted
treatment.
These were important steps, no doubt about it, but we can and must
do more. As we continue to consider further action, I am committed to
ensuring we have strong congressional oversight over Cures and CARA so
they have the intended benefits and impact for patients and families.
There's a whole lot more to discuss, but I would also like to make
sure we leave as much time as possible for questions.
I would just again thank you Chairman Alexander, and all our
colleagues for their continued efforts to tackle this pressing
challenge.
I know there are many efforts being spearheaded by our colleagues
on this Committee that would make progress and build upon our work thus
far. I hope our discussion today can better inform and add to all those
efforts.
Thank you again to our witnesses, I look forward to your testimony.
______

The Chairman. Thank you, Senator Murray.
Senator Baldwin, Senator Whitehouse, you both have
witnesses here. I've introduced them, but if you'd like to say
another word about them now before we go to Senator Paul,
you're welcome to do that.
Senator Baldwin.
Senator Baldwin. You can go first.

Statement of Senator Whitehouse

Senator Whitehouse. Well, I just want to welcome Rebecca
Boss here, who is the Director of our Department of the
unfortunately named Behavioral Healthcare, Developmental
Disabilities and Hospitals. But we call it BHDDH. She has been
working to serve those struggling with addiction for more than
25 years, working as a clinical supervisor and program director
before joining the Department in 2004. She became the Acting
Director in 2016 and was confirmed as Director this May.
Director Boss helps ensure that Rhode Islanders facing
addiction and other behavioral health issues have access to
high-quality prevention, treatment, and recovery services. She
was very active at meetings and roundtables I held while
drafting the Comprehensive Addiction and Recovery Act, and was
integral in developing Rhode Island's Overdose Prevention and
Intervention Task Force Action Plan. She has received state and
national recognition for her work on developing and
implementing AnchorED, a program that connects overdose
patients in emergency rooms to peer recovery coaches.
Director Boss studied psychology at the University of Rhode
Island, and received her Master's Degree in Counseling and
Educational Psychology from Rhode Island College. Rhode Island
is very proud of her.
Thank you for coming here today.
Thank you, Chairman.
The Chairman. Thank you, Senator Whitehouse.
Senator Baldwin.

Statement of Senator Baldwin

Senator Baldwin. Well, thank you for this opportunity, Mr.
Chairman. I am thrilled to welcome Dr. Andrea Magermans to the
Committee.
I know you've been introduced, but I'm particularly
thrilled because I really think Wisconsin is leading the Nation
with its new Enhanced Prescription Drug Monitoring Program, the
ePDMP. It's a mouthful, but it is truly a state-of-the-art
system. Not only is it a reporting tool, but it is also a
prescribing assessment, public health and communication tool,
and it's able to integrate directly into the medical record.
More than 48 million prescription records have been
submitted to the PDMP, and it's helped contribute to an over 11
million decrease in the number of opioid doses dispensed.
Importantly, this system was developed with end users and
providers themselves to make sure that it works for them.
I am really proud of this innovative tool and the work that
you've done, your long-term experience in the State of
Wisconsin. We know that this tool is critical to our fight
against the opioid epidemic.
Welcome to the Committee, and thank you for sharing
Wisconsin's story with our panel.
The Chairman. Thank you, Senator Baldwin.
Now to continue with our round of questions, Senator Paul.
Senator Paul. You know, as a physician, it pains me to
acknowledge that I think a big part of the problem is physician
prescribing habits. I think those were also influenced by some
misinformation from the drug companies on the idea that
OxyContin wasn't that addictive. It turned out to be maybe just
a little bit untrue.
I think that when we look at prescribing habits and we look
at changing, we've been talking about this, and in Kentucky
we've done some good things. We closed down some of the pill
mills. We got rid of some of the checking prescriptions to make
sure people weren't doctor shopping and duplicating. But we
still have a county that has 21,000 people in it that had 2.8
million doses of OxyContin prescribed, OxyContin and Percocet.
I lump them all together. That's 150 doses for every person who
lives in the county.
Something is wrong, and we think we've gotten rid of the
worst doctors that were out there doing it, and this still
occurs. Something is wrong in our habits. From when I went to
medical school, this is sort of the conundrum. Doctors don't
want people to hurt, you know? I recently was the victim of an
assault and had six ribs broken, and I was given opioids of
some sort, and I finally made the decision just not to take
them, not because I was worried that I would be addicted,
although I was going to need four to 6 weeks of them, but I
took large doses of Ibuprofen. People are, like, oh well,
Ibuprofen is Advil, that's no good. Well, it does control pain.
I still had a lot of pain, but I did get some relief with
Ibuprofen. People think that's not good enough because it's not
a narcotic, and I just don't think we've studied these things.
There is an evidence base in medicine on a lot of this to
know. It reminds me of my wife when she was having a baby. They
gave her morphine. She said, well, I was drunk as hell, but I
still hurt like hell. You know, it affected her sensorium but
it didn't cover her pain. She liked the Epidril a lot better,
to tell you the truth.
There are ways to control pain, but I think we have made a
mistake in over-prescribing. They say that four out of five
heroin users started with prescription medication. Certain
people are probably more prone to addiction than others, but
they got on it, they got hooked, and then they somehow switched
to heroin.
I guess my question for Secretary Tilley is we cut down the
pill mills, we're cutting down duplicate, but we still have
this massive prescription of pain medications, and when I talk
to the doctors they say, well, they've been on it forever, and
they're on four. They are tolerating it. A lot of them are just
addicted and they're tolerating three or four and they're not
dying from it, but it's still not a great life.
We've got to figure out a way--some of it should maybe come
from the medical community, that we need to change what our
recommendations are and how we practice. But do you have a
recommendation, Secretary Tilley, on what we've done so far and
why we still have counties with 2.8 million doses of opioids
being prescribed?
Secretary Tilley. Senator, yes. I was going to mention the
same county and those same numbers that I shared with Andrea to
my right.
First thing, Kentucky is the first state to mandate the use
of a PDMP. I think Castro was one of the first in the country
to do that.
Second, we were the first state in the country to limit
based on CDC recommendations. Just this past legislative
session, the Governor dug his heels in on this. It was not easy
to limit the prescription of opioids for acute pain to 3 days,
because the CDC says between three and 5 days addiction begins.
We're the first state to do that. You've got to shrink the size
of the funnel at the top to keep these opioid dosages from
coming into communities, and that's the first step in that
regard.
To your point, too, again, I mentioned the book Dreamland
only because I think I'm compelled to do it for the notion that
I think we were sold a bill of goods, and I'll leave it at
that. I think physicians were sold a bill of goods. After
understanding what morphine can do to people in the day, and
now moving forward into the `90's, what is chronicled in this
book should be read by everyone who has a concern for this
problem.
That said, at the University of Kentucky there is a new
protocol to do just what you said, and that's begin with
everything but an opioid rather than the opposite. Why begin
with a narcotic? Begin with everything to deal with pain, the
narcotic being the absolute last resort, and in a controlled
setting a narcotic can be effective. It can't be diverted,
potentially. That's why the injectables are coming online.
At UK, there are two patents pending. One is for injectable
buprenorphine, but that's a little off, but that's non-
convertible. It can deal with the addiction. The second is a
mist for naloxone. But again just to say the kind of innovation
in the medical community I think answers your question.
Senator Paul. Here's one quick suggestion. As physicians,
we don't want to be told what to do too much, and people need
pain medications, and some physicians fear it will be too
controlled and people will suffer with pain. But one of the
things you might consider--and I don't know if you've done
this--is go to the head of the medical society or the state
board and have them go to these counties and just have a
meeting with the medical society of 10 or 20 doctors and let
them know these are your statistics and that you are outside
the parameters, not put people in jail but let people know,
because I think somehow there could be some sort of persuasion
maybe within the medical community, even stronger than just
universities. Universities probably aren't as big a part of the
problem as communities are where people are decades-long
addicted, you know?
Secretary Tilley. If I could, Chairman, just quickly on
that point, I would credit the medical community nationally but
also in Kentucky for recognizing that the posture was so
defensive 5 years ago when we began trying to legislate our way
out of this to a certain extent, and today it's much different.
We have done just what you suggested, and I think it's an
excellent suggestion. We need to do more of that, and that's
why you see the medical schools now upping their training
requirements for prescribing practices for opioids, as an
example.
The Chairman. Thank you very much, Senator Paul.
Senator Bennet.
Senator Bennet. Thank you, Mr. Chairman.
I would join Secretary Tilley in recommending Sam Quinones'
book about this. When you finish Dreamland, you really have to
ask yourself what we're doing here as a country. I mean, 50,000
people a year are now dying, and we really haven't responded.
In my state, in Colorado, especially in rural parts of the
state, although it really is everywhere, but in rural parts of
the state there is no more access to addiction treatment today
than there was 10 years ago when this started, none. If you go
to the San Luis Valley and have a town hall, you'll have three
or four questions today, but 6 years ago, 7 years ago, nothing,
and there is still no additional addiction treatment, except
for what's happening in the jails, and I'm going to come to
that.
I want to ask Director Boss a question first. Today's
Denver Post reports that we have had an increase in Colorado of
newborns addicted to opioids that's 80 percent between 2010 and
2015. I can only imagine that number is worse in 2017. In some
parts of Colorado, the rate is even higher. Parkview Medical
Center in Pueblo, the city's safety-net hospital that sees many
Medicaid patients, the rate of newborns addicted to opioids
skyrocketed from 0.7 per 1,000 people in 2010 to 20.8 per 1,000
people in 2012. The rate now hovers around 10, and doctors have
noted a shift from prescription drugs such as OxyContin to
street drugs, mainly heroin, in recent years. I'm quoting from
this Denver Post article.
The article went on to state that the number-one cause of
death for pregnant women and new mothers in Colorado is drug
overdose. I wonder, based on your work in Rhode Island, what we
should be thinking about in Colorado and other places when it
comes to caring for mothers that are addicted and their
newborns who are addicted.
Ms. Boss. Thank you, Senator Bennet. I do know that we are
seeing an increase in the number of women who are overdosing as
a result of opioids, and that fact can't be forgotten in terms
of the importance of the addiction on the family and, as you
mentioned, on the newborns. We are seeing an increase in
neonatal abstinence syndrome. We have a workforce in Rhode
Island that is addressing that issue.
It's important to remember that infants aren't born
addicted, which implies behavior. They're born dependent on a
substance, and there is medical treatment for that condition
when they're born dependent on a substance, and the use of
medications, which can be methadone or buprenorphine, may also
increase those born, but those are the treatments that are
recommended.
It's important as we look at the increase, it may reflect
an increase of individuals who are being appropriately treated
with medications for their addiction, and the care of the
infants is really important.
One of the things that has come through in the last few
years, through Congress, has been an increase in PPW funds, and
I think that the Pregnant Postpartum Woman funding for
treatment is critical. If we look at programs that are
effective in addressing women, we have to provide funding for
programs that will treat the children of these women as well.
Addiction affects the entire family. When women are adequately
supported and given the tools for recovery, they recover. The
importance is providing the funding for that, and I appreciate
the work that's been done thus far, and I look forward to our
work going forward and providing more support to those
individuals.
Senator Bennet. But, Secretary Tilley, at the last hearing
we had on the opioid crisis I asked what we could do to help
people struggling with prescription drugs or heroin addiction
that have lost their Medicaid coverage because they've been
placed in jail. Colorado counties especially, again, are rural
areas and struggle to find money for addiction treatment and
care, and management for inmates who are cutoff from Medicaid.
There is agreement from the witnesses that a jail is a pretty
lousy place to administer addiction treatment. I know, partly
because I read that book, that Kentucky has done some important
things here, and I wonder whether you'd be willing to share
that in the last minute or so that we have.
Secretary Tilley. I will, and certainly I thank you for
that. A suspension of Medicaid so that it doesn't take as much
red tape to get it going again on release of that inmate is
critical, so that's something I would consider.
The use of social service clinicians. Again, social
workers, immediately upon release, to link that inmate right
back to whatever resource they need.
I would also say that access doesn't always equal outcomes.
Certainly we need money at every turn for treatment, but there
certainly are ways to be innovative, and there are ways to use
that money in targeted and surgical ways to set up just the
kind of outcome-based interventions that can work for those who
are leaving prison or jail.
I am one who also thinks that the best kind of treatment
does not occur. It's absolutely essential to have it behind the
walls of prisons or jails. But the best kind of treatment
doesn't always occur there. That's why the use of sometimes
controversial civil commitments in Kentucky--we call it Casey's
Law, Senator, after a young man, Casey Wethington, died of an
overdose years ago. We've had some trouble expanding that. It
works, but it could work better.
To use civil commitments would then preserve whatever
benefits, like Medicaid, that individual may have in a civil
setting, as opposed to an incarceration where they would lose
those benefits.
You've touched on something very critical, and again, we
just try to link people back to it as quickly as possible.
We're also trying to release people into treatment facilities
with some parole practices that are unique. We're working on
those today so that we identify those. What we found is
incredible.
The Chairman. You're over the 5 minutes.
Secretary Tilley. We found we have far too many people with
possession-only offenses in prison. That's a shocker, I know,
but it's not better than it was 10 years ago.
Senator Bennet. Thank you.
The Chairman. Thank you, Senator Bennet.
Senator Isakson.
Senator Isakson. Thank you, Mr. Chairman.
I want to commend Dr. Abubaker and all of you for
testifying today. It's a very important hearing. In fact, it's
probably the most important hearing from an educational
standpoint that we could possibly have, and I thank Chairman
Alexander for calling it.
I want to get everybody to look at this, the next-to-last
paragraph of Dr. Abubaker's prepared remarks. It's in your
book. I want to read two things in there that are critically
important, and I want to tell you why.
Dr. Abubaker says, ``I'm worried we will not address the
root of the current opioid epidemic, which are addiction and
mental illness as the underlying reasons for all drug epidemics
we have been through and face in the future. If we do not
address the foundation of these epidemics, I fear that another
drug epidemic will emerge from now, and another generation of
Americans, maybe even our own grandchildren, will be faced with
a drug crisis of a different kind. We had better not let this
happen. With the knowledge we have now about brain function and
how addiction affects it, to let future generations of
Americans be affected by similar crises in the future would be
a historical abdication of our responsibility to do good for
our country.''
That is a powerful paragraph. It's powerful to me because I
lost my grandson, Charlie, December 8th of last year to a drug
overdose. Charlie would be the first person to tell you, if you
can cure the addiction problem, not the pain problem but the
addiction disease, that probably wouldn't have happened. I miss
Charlie to this day, and I have always sworn that I'm going to
use that loss when I can to help, as you did today in your
testimony.
Others understand that those tragedies don't just happen to
other people, they happen to us. They can happen to us.
Second, I had a unique experience this year. I had two
major back surgeries, one in February and one in March. I
learned a whole lot of about OxyContin and hydrocodone and lots
of things I didn't know anything about that I thought were just
pills to make me feel better. But the ramifications and the
potential amplifications of taking those medicines at the age
of 72 for pain can get you in a whole lot of trouble.
I remember when my surgeon had me interview with a mental
health specialist before the operation to talk about what the
anesthesiologist was going to recommend to me as a pain
management regimen. I knew this must be a pretty big issue.
It's not like taking an aspirin.
I think your testimony is powerful in what we all can do.
One is to try to better educate the educational establishment
of physicians and providers to the role they have in limiting
the exposure people will ever have to these opioids, and
hopefully depending on other ways of treating pain that avoid
it entirely. With both of my surgeries--and I'm not trying to
sell a product here, but Tylenol was my pain management
medicine of choice. I would have never thought that going in
for the operation, but realizing what happened to Charlie and
his overdose with an opioid last year, I realized how that
counseling saved me and helped me a lot in mine.
I want to thank you for your willingness to testify about
your own personal experience. But I do think you're right, the
mental health aspect and the addiction disease are the things
we really ought to focus on as a Committee and as a country. If
we don't, there's a worse price to pay later on in another
generation. We don't know what that price will be, but we know
it's there if we don't deal with this now.
I just want to thank you for your testimony.
I thank you, Mr. Chairman, for bringing this to everybody's
attention, and I'll yield back my time.
The Chairman. Thank you, Senator Isakson.
Senator Franken.
Senator Franken. Thank you, Mr. Chairman, for this hearing.
Dr. Abubaker, I'm sorry I wasn't here for your testimony,
but I read it last night, and I was very moved by all your
testimony and describing the tragic death of your son, how it
motivates your work.
In your testimony you note that the problem is not solely
opioids and that we need to move the conversation to dealing
with addiction as a disease of the brain, and I agree 100
percent, and I appreciate the work you're doing to educate
medical and dental students on appropriate prescribing
practices of opioids.
I firmly believe that all clinicians need this training.
That's why, as part of the 21st Century Cures Act, Senator
Cassidy and I championed a provision to grant funding to
improve training for medical schools and medical students and
dental students and practitioners and nursing students and
practitioners and social workers.
Our Nation's clinicians need to know when they see someone
who has an addiction problem, and I don't think they get that
training. They don't get that training in medical school. They
don't get that training, and we need to have that training.
That was the purpose of that.
Dr. Abubaker, the CDC recently released prescribing
guidelines for medical providers who are prescribing opioids
for chronic pain. How will these guidelines help change opioid
prescribing practices?
Dr. Abubaker. Thank you, Senator. In my profession and
specialty, oral surgery, the major emphasis for our training
for students or residents is acute pain. There are a few
instances where we deal with chronic pain, something called
TMJ, if you've heard of it. That usually turns into chronic
pain. The guidelines in general, in principle, for the
management of acute and chronic pain is compassion for the
patient's need. Historically, we thought the compassion equaled
the number of tablets or the strength of the medications.
I think we have to go back to compassion as what hurts and
what harms the patient and what benefits the patient. Sometimes
the non-pharmacological management for acute pain--and I'm not
a specialist, so I have to explain that I have no expertise in
chronic pain. But from my perspective, the compassion for the
patient, some patients will need opioids, long-term opioids,
but we have to individualize the treatment.
Also, we offer tailored treatment to the individual, for
some people spiritual or maybe some other non-pharmacological
agent, sometimes mild pharmacological agents. But clearly, the
bottom line is the scientific basis and the evidence-based
management. I think the CDC recommended that kind of guideline.
Senator Franken. Senator Isakson read the last paragraph
and talking about this as a disease of the brain and being
resilient for the next addiction crisis. I think this is one of
the reasons that we have to fund NIH funding and mapping the
brain. I think that's so important.
I have so much to ask about. I hope we'll be able to get a
second round.
Ms. Boss, I was so impressed by what you put together in
Rhode Island, and I certainly hope that is being studied and
copied, the Anchor MORE Program, the coaches, the recovery
coaches. What I was really interested in was how they seem to
be everywhere and how you trained them up, and how you made
sure that--Senator Bennet talked about how there's not enough
treatment. We need more treatment, and we need more counselors.
One of the problems in my state is Indian Country. I'm
going to try to get done before my time runs out so you can
answer the question of how you did this. But in Indian Country,
when they say culturally specific, many times that means an
Indian provider.
How did you train all these people? How did that happen?
Ms. Boss. We have specific training for our recovery
coaches, and they actually go through a certification process.
But for those that are dealing with individuals who are high
risk, we enhance that training even more. The Anchor MORE
outreach counselors that go to data-identified hot spots where
there's increased activity with overdose or fentanyl in the
area, they are specifically trained to distribute naloxone,
teach people how to use naloxone. They're specifically trained
to motivate people to want treatment. This is where we need to
identify. We have treatment available. We have to get the
people to that treatment. Sometimes, in providing the hope of
recovery, I've done it, I've been where you are, I know what
you're going through, life can get better.
Often times, when people are in the midst of their
addiction, they don't see that opportunity to get better.
Recovery coaches who have been there are able to provide that
spark of inspiration that there might be an opportunity for my
life to get better. They're actually going out into the
community to find these folks, not waiting for them to overdose
and show up in the ED.
The Chairman. We're running out of time.
Ms. Boss. Thank you.
Senator Franken. Thank you.
The Chairman. I'm going to--we all have important
questions. We have 10 Senators who haven't had a chance to ask
questions yet, I'm going to keep a pretty strict rule on the 5
minutes for questions and answers, if everyone would respect
that, my colleagues.
Senator Cassidy.
Senator Cassidy. Thank you. Thank you all for what you do.
Ms. Magermans, I really like your PDMP, and I'm asking
questions not to diminish but to understand. It seems like you
are a model for what everybody should be doing. But when I look
at the number of opioid deaths in HIV from your Wisconsin DPH,
you've actually increased since implementation. I say that not
to accuse but to understand. Why, with such an incredibly
effective program since 2013, have opioid deaths risen from 350
to 400, that sort of thing?
Ms. Magermans. Thank you, Senator. I think we can see that
there is a reduction in the opioids that are being prescribed
and dispensed. However, there is an increase in overdose
deaths, and I think it's because of the presence of the
fentanyl and the fact that there are heroin overdose deaths
with----
Senator Cassidy. Let me ask, because I'm looking at these
stats--I can share this, but it's from your government.
Ms. Magermans. Sure.
Senator Cassidy. The prescription opioids are also up
sloping. It's the heroin, but also prescription opioids. So,
any thoughts about that?
Ms. Magermans. I think it's a slow process. I think that
the prescribing has effects later on down the road. Reduced
prescribing, there are people who are already addicted and who
may end up overdosing, and I think it's really just moving in a
new direction once you do start curbing some of the
prescribing. I think the effects will be later.
Senator Cassidy. A lag time before effect.
Ms. Magermans. Exactly.
Senator Cassidy. What do you do with your data? Do you
proactively refer--you implied you did, but to confirm, do you
proactively refer a physician who is an outlier, three standard
deviations out? Do you proactively refer she or he to law
enforcement?
Ms. Magermans. To law enforcement? No. The Controlled
Substances Board oversees the program in Wisconsin, and the
Controlled Substances Board has the authority to refer to the
licensing board, a physician to the medical board, an advanced
practice nurse prescriber to the nursing board, et cetera.
Senator Cassidy. There is a pattern of physicians that are
pill mill doctors. They move from state to state to state to
state. I say that as a physician; and, as Dr. Paul said,
regretfully so.
Is there any way to track a risk factor for a doc being a
pill mill doc? I see Secretary Tilley nodding his head, so I'd
love to have your input as well. My gosh, licensing board, he's
lost his license in three other states. It seems like there
should be a trigger for someone to monitor.
By the way, I'll tell you, I once had a drug rep come up,
and she said I know who the pill mills are, because I can go to
their office and there's a certain clientele. Somebody pays
$300 for an initial visit, and they walk out with a handful of
prescriptions 5 minutes after entering the exam room. I'm
thinking, a drug rep can figure this out. Not to diminish her,
but she's just observing, and everybody with their data bases
aren't coming to the same conclusions. Hats off to her, but
it's a little bit indicting us.
Any thoughts on that?
Ms. Magermans. Speaking of the Wisconsin PDMP, the data is
about prescriptions that are dispensed in Wisconsin. A
prescriber that first practiced outside of Wisconsin would not
have PDMP data that is analyzed with the Wisconsin PDMP data.
However, things like the average distance that patients travel
to see a----
Senator Cassidy. I don't mean to cut you off. I just have a
minute 38 seconds.
Secretary Tilley, you were also nodding your head when I
spoke about these pill mill docs. Any thoughts on that?
Secretary Tilley. Yes, a number. But in a minute I would
tell you very briefly that we are tracking that data. A company
is helping a number of states do that as well, red flagging,
letting doctors know where they stand as well, so they can look
and see. They are often getting busy, not understanding how
many they may be prescribing, seeing some of those red flags
themselves to be able to self-assess.
Senator Cassidy. If a doctor is going from Indiana to Ohio
to Tennessee to your state, and somehow there have been flags
along the way that the doc is a pill mill doc, would you know
that?
Secretary Tilley. We would. There's only one state we can't
collaborate with now. Of the seven border states of Kentucky,
Missouri is the only one where we're trying to get there. Not
to be critical, but it's the reality. But we do know that. We
can track that.
Senator Cassidy. Okay. Does that affect the licensing of
that physician to obtain a medical license and/or the
surveillance of his practice once you so identify?
Secretary Tilley. One of the challenges has been the Board
of Medical Licensure in our state. They have come a great ways
in that area, but I still think they need to be more aggressive
in making certain that docs who are over-prescribing, No. 1,
know it and have a chance to correct it, and if they don't, are
sanctioned for it.
Senator Cassidy. Next, Ms. Boss, I have a few seconds left.
You mentioned in your testimony giving MAT to people in prison.
Did you mean jail? In other words, short-term imprisonment? Or
did you mean prison? In other words, they're going to be there
for 10 years?
Ms. Boss. I meant both.
Senator Cassidy. If they're in prison, there for 10 years,
you must have a problem with contraband?
Ms. Boss. The program has been in effect for about a year,
and we have not, as far as I understand, not seen an increase
in contraband. Now, please know that we don't provide MAT for
an individual who has a sentence of 10 years until prior to
release. If someone has a history of opioid dependence and
they're leaving and they are at risk for overdose and are
appropriate for medication and want to get on medication, we
are willing to provide that medication prior to release, but
not for a 10-year sentence.
Senator Cassidy. I'll finish by thanking you, Dr. Abubaker,
for your powerful testimony.
I yield back.
The Chairman. Thank you, Senator Cassidy.
Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman.
Thank you all for being here. We have other hearings; we're
in and out. But this has been very, very helpful.
I have a few questions. I'll just start by noting that it's
very hard to confront this epidemic when we are threatening to
pass health care legislation that would remove $800 billion
from Medicaid, which is the program that ends up treating 40
percent of addiction clients in this country. We're about to
vote on a piece of legislation later tonight that would trigger
automatic cuts, in the neighborhood of $25 billion, to
Medicare, $1.7 billion in the first year alone to the social
services block grant. I think this is all really, really
important and helpful, but we're going to make your life a lot
harder if the legislation that has been pending throughout the
year becomes the law.
Ms. Boss, I wanted to follow-up on your testimony
mentioning Rhode Island's efforts in promoting non-opioid
therapies for chronic pain. Senator Paul asked a little bit
about this, and I'd be happy to hear others' testimony on the
panel to this question. But can you just talk a little bit
about what the barriers are today to getting non-opioid, non-
drug-based therapies for pain? Amongst them that I've heard is
insurance companies making it a lot easier to get reimbursement
for a drug than it is for physical therapy or acupuncture, the
lack of providers in this space if you try to find alternative
pain therapies.
I'd be happy to hear others' testimony, but you raised it
in your prepared remarks, so let me pose it to you first.
Ms. Boss. Thank you. Our efforts to combat this epidemic
are really in four areas, the first being prevention. We've
done a lot of work in terms of trying to reduce the supply of
opioids and the prescribing of opioids and making sure that
they're appropriate. A lot of the work that's been described
previously has been done in Rhode Island as well.
One of the things that we focused on, and our Department of
Health is very active in working with the medical community to
look at alternative pain management therapies, and the work of
our legislature, and the work of our insurance company and
Office of Health Insurance commissioner to make sure that there
is adequate coverage for alternative pain management therapies.
Things like massage, things like acupuncture, things like
chiropractic are important in combatting the pain that
individuals suffer without opioids. We've done a lot of work
engaging multiple stakeholders in making sure that the
insurance companies around the table, they have a seat at the
Governor's Overdose and Intervention Prevention Task Force, and
making sure that our legislators are on board in terms of
promoting insurance coverage for alternative pain management
therapies. That's really where the importance is.
We haven't seen, to my knowledge, a lack of capacity within
that provider system. It's really about whether or not people
can afford it, and people can afford it generally if their
insurance coverage is going to cover it.
Senator Murphy. How are we doing on that? I mean, you're
working on it, but do you see insurance benefits today covering
the range of alternative pain therapies that should be covered?
Ms. Boss. I believe that we are making progress. I can't
say that 100 percent of all insurance in Rhode Island covering
the alternative pain management therapies is as much as we
would like to see, but I think that we have made progress and
that those pain management therapies are being covered by most
insurance.
Senator Murphy. Secretary Tilley, do you have anything to
add?
Secretary Tilley. It's a challenge for us. We have a system
of managed care. We are trying to work with those providers, do
master agreements with them to cover. The challenge is
certainly sometimes the companies don't see that individual as
a long-term health concern for them, so the immediate need is
to cut pain at less cost rather than to improve their lifestyle
through physical therapy, through nerve blocks. You mentioned
all the others, so I won't repeat them.
That is the way to partially get us out of the need for so
much pain medication, even if it is a Tylenol, which certainly
is much less problematic than the narcotics we're discussing
today.
Yes, the challenges are great. Again, my umbrella in the
justice cabinet is pretty broad, from corrections to public
defenders to everything in-between under the umbrella of
justice, but we are working daily in justice because this
problem is so pervasive in the criminal justice system with
public health, with the health and family services branch, with
the insurance companies on these issues to try to get them to
come to the table.
I can't possibly finish that in 27 seconds, but you've hit
a nerve, let's just say that.
Senator Murphy. Maybe there's not legislation on this, Mr.
Chairman, but just potentially the opportunity to use a
bipartisan bully pulpit to make clear to the insurance
companies that this is in their best interest to ultimately pay
for these alternative therapies. It might cost a little bit
more money up front than the bottle of pills, but in the long
run it's going to save you an enormous amount of money.
Thank you, Mr. Chairman.
The Chairman. Thanks, Senator Murphy.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman. Thank you to
each of you this morning. We truly appreciate your testimony,
your work, and just the effort to deal with this epidemic,
pandemic, as we have been describing it.
Senator Bennet mentioned that so much of the challenge in
many of our states is the rural aspect. It may be that you can
get coverage for treatments, but if you can't get to the
treatment, it's pretty difficult.
Ms. Boss, you acknowledge in your recommendations that many
individuals living with substance abuse disorders don't have
access to transportation. You just can't even get there.
One of the things that we've been working on in Alaska,
because again we simply don't have sufficient treatment that is
available, and the distances are limiting, the FDA has just
recently approved a device that's called the bridge device.
We've been working in certain areas to--it's an ambulatory
detox model, and through the use of the bridge device, which
reduces the symptoms of those who are going through withdrawal,
along with medically assisted technologies, the MAT, using
Vivitrol and counseling, we have been trying to use this as
this effort to fill the gaps until we're able to get more
treatment facilities that are online. We've got the potential
for additional facilities, additional beds coming on, but it
may be 2 years from now, maybe even longer than that. As we all
know, none of these individuals have 2 years to wait.
Being able to share some of the pilots that are going on in
different areas, particularly as we're struggling with how we
deal with the realities of rural restrictions, things that
limit us from any level of treatment whatsoever. I will note
that in our state, the benefit that has come to us in being
able to treat more through Medicaid expansion has been quite
significant for us as a state.
I wanted to ask a question that, Secretary Tilley, you
reference in your written testimony but you just kind of
skirted by it, and that is the issue that we're beginning to
see with outbreak of HIV or hepatitis because of the needles
that are being used to inject heroin. I'm actually going to be
meeting with a member of our state health and social services
department with a specific focus to the syringe services
program that we are trying to implement in the State of Alaska.
Can you, or if others have more information on this--
because we're dealing with an opioid epidemic. But again, are
we also leading ourselves to a hepatitis epidemic, a resurgence
of HIV? Can you please speak to this?
Secretary Tilley. Yes, Senator, I absolutely can. In
Kentucky we became the first southern state 2 years ago to
legislate a comprehensive statewide program, very
controversial. Again, I think people thought I had three heads
when I stood up on the House floor when I was in the
legislature to talk about it for the first time. I did that,
and now we have 41 programs in a state, again, that is in
desperate need of this because our Hep C rates are seven times
the national average, our HIV rates are off the charts. Of the
220 counties most susceptible, according to the CDC, of a rapid
HIV outbreak, 54 of those counties are in Kentucky.
The Senator from Indiana mentioned the problem. I'm right
across the river from Louisville. It happened in Austin,
Indiana, many of you know by now, with rates of HIV and their
outbreak like that of Sub-Saharan Africa. That was instructive
to us on how close we were to that kind of public health
nightmare. We're proud of this effort now to move forward on
that.
I would say as it relates to corrections, we don't treat
now without symptomology. If there would be some requirement to
do that--and this applies to many states around the country
moving forward--I don't know how the existing tax base could
withstand an additional $100 million burden to treat for Hep C
on the front end without symptomology, which again we can do
today.
Again, to say you've hit a nerve, you absolutely have.
Anything we can do in the public health arena to cut down the
blood-borne illnesses is critical to this entire problem.
Senator Murkowski. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murkowski.
Senator Hassan.
Senator Hassan. Well, thank you, Mr. Chairman, and Ranking
Member, for having this hearing. Thank you and good morning to
all of our panelists.
Dr. Abubaker, thank you so much for speaking up. I also
want to thank Senator Isakson for talking about his grandson.
I was Governor of New Hampshire before I took on this role,
and so I've been dealing with the opioid epidemic in my home
state, where it is absolutely devastating, since 2013, and I
have to start by saying that if this were any other kind of
public health crisis that was taking 100 lives a day, which is
about what the opioid overdose death rate is right now, if this
many people were dying in a defective plane every day in the
United States of America, we would be devoting considerably
more resources to it.
Part of the reason we haven't is because of the stigma that
has traditionally come with addiction. So, doctor, your
speaking up about your son, Senator Isakson speaking up about
his grandson, the people in this room, and I know there are
many, who have lost loved ones or who have struggled with
addiction themselves speaking up about it is critical to this.
We need a long-term strategy to solve this complex problem,
and that requires funding to support those on the front line of
the crisis. The Trump administration has so far refused to
request additional funding to fight this crisis, and yesterday
I pressed the HHS Secretary nominee on the issue because we
need the Administration to send to Congress a supplemental
funding request so that we can appropriate more funds and
resources.
For each witness here, I just would like a yes or no
answer: Do you think additional funding is necessary? I'll
start with Dr. Abubaker and just go down the line.
Dr. Abubaker. Yes.
Ms. Boss. Yes.
Ms. Magermans. Yes.
Secretary Tilley. Additional--and I apologize. I have to
ask a question to clarify something. Additional funding for
addiction treatment? I'm sorry, I apologize.
Senator Hassan. Treatment, prevention, and recovery. But do
we need more funding on the front lines?
Secretary Tilley. Yes.
Senator Hassan. Thank you.
To Director Magermans, I want to thank you for your
leadership in helping us understand how PDMPs are really
critical to combatting this epidemic. I just wanted to drill
down a little bit. While states can benefit greatly from these
electronic data bases, there continues to be some difficulty in
ease of use and accessibility. PDMPs are only informative if
prescribers actually utilize them.
Do you believe that integrating PDMPs into electronic
health records will promote better work flow for providers and
increase the likelihood that they would use PDMPs?
Ms. Magermans. The short answer there is absolutely, yes.
Senator Hassan. Okay. Do you think substance use counselors
and mental health providers who often work with patients
experiencing substance misuse disorders on a longer-term basis
should have access to PDMP data as well?
Ms. Magermans. In Wisconsin, substance abuse counselors
licensed by the Department of Safety and Professional Services
can access the PDMP, and the feedback that we have received
from them is that it is a very valuable tool. We have other
social workers with a specialty in substance abuse disorder
treatment who access it as well, and they also say that it is a
very valuable tool. I would say yes.
Senator Hassan. Okay, thank you.
To Secretary Tilley, I appreciated your testimony about the
coordination between law enforcement and public health
officials in Kentucky. We know that this is an epidemic that
knows no bureaucratic boundaries, and we need to ensure that we
are breaking down the silos between different agencies and
officials, silos that can prevent us from responding
appropriately to the epidemic, something I focused on when I
was Governor. In New Hampshire we're doing some really
interesting work. It's called Safe Stations. Through that
initiative, firefighters are available 24/7 at participating
stations to help connect individuals in need of treatment or
recovery services so that people struggling with addiction know
about the resources available to support them on the road to
recovery, and so that firefighters can help with what we call a
warm handoff to peer support or treatment.
I am very proud of our brave firefighters for all they do
to strengthen public safety and public health, including really
driving this important initiative.
Could you talk a little bit more about the importance of
ensuring that public safety officials are helping us address
these public health issues and whether you think programs like
Safe Stations can help us turn the tide?
Secretary Tilley. Absolutely. First responders are critical
in this because they're the boots on the ground, first to
respond. Again, things like needle exchange programs make it
five times more likely that they touch the people on the ground
where they are, the harm reduction model, find them, get them
into treatment. That's part of the untold story there.
LEAD, the Law Enforcement Assisted Diversion, is to get
those mentally ill and addicted into treatment rather than a
prison cell or a jail cell. That's very critical. Again, our
Governor, having a very good connection to New Hampshire, we
know about Safe Stations, and that is a great program. We need
to do more of that.
I also cannot go without mentioning our Angel initiative.
We have a very dynamic State Police Commissioner who has spent
a lifetime at the DEA, and he understands the need to do this.
That's why we've made such tremendous progress in a very short
period of time. Again, the Angel initiative is anyone can come
in with paraphernalia, addicted, throw down that in a police
station setting and be connected to treatment that same day. We
guarantee that treatment bed the same day, no criminalization
of any kind.
Senator Hassan. Thank you very much.
Thank you, Mr. Chair.
The Chairman. Thank you, Senator Hassan.
Senator Sanders.
Senator Sanders. Thank you, Mr. Chairman, for holding this
important hearing, and let me thank all the guests for being
here. A lot of questions, short period of time.
Let me just begin by saying that in my small State of
Vermont, we have lost 112 people last year as a result of
opioid overdoses, and that is three times more than who died in
2010. In 2015, Vermont had the fifth highest prevalence rate of
heroin use in the country, and in 2016 heroin-related emergency
room visits increased by nearly 20 percent. Even in a small,
beautiful, rural state, we have an epidemic.
OxyContin's manufacturer, Purdue Pharma, pled guilty and
agreed to pay more than $600 million in fines in 2007 for
misleading the public about the risks of OxyContin. But the
drug continued to rack up blockbuster sales, generating more
than $22 billion in profits over the last decade.
Should the pharmaceutical industry and companies like
Purdue be treated the same way as the tobacco industry was
treated decades ago? The tobacco industry killed millions of
people in this country, and they lied to the American people
about the health impacts of their product. Purdue and other
companies produced a product, forgot to tell doctors or the
people that it was addictive, thousands of people have died and
suffered as a result.
Should we--brief answers--hold those companies responsible
in the same way we held the tobacco industry?
Dr. Abubaker? Brief answers, please, because I have other
questions.
Dr. Abubaker. Research and development for development of
treatment for addictions and treatment for pain medication
that's not addictive, at least on that level.
Senator Sanders. Ms. Boss.
Ms. Boss. I would agree with the doctor. I'm not sure I'm
really qualified to answer that question but would want more
information on what kind of accountability we'd be looking for.
Senator Sanders. Ms. Magermans.
Ms. Magermans. I'm not qualified to answer that question.
Senator Sanders. Secretary Tilley.
Secretary Tilley. I may not be qualified, but my answer is
yes, unequivocally. Kentucky settled a lawsuit years ago--well,
they settled it, but it began in 2007, which should have been a
billion-dollar settlement, at minimum, for the devastation that
was caused in Appalachia in particular. It was a $24 million
agreement to settle that is now still sealed. We don't even
know what has been said. A deposition of one of those lead
figures in this at this point is still silenced.
Senator Sanders. Mr. Chairman, I don't understand--and I
agree with Secretary Tilley. I just don't understand how we
allow a situation to continue where these companies make
billions of dollars in profit who essentially lied to
physicians, lied to the American people, and have caused an
epidemic. We've got to deal with that.
My next question is I think we all understand that we need
additional resources for treatment, and I don't mean to be
overly political here because I know that everybody--
Republican, Democrat, Independent--is deeply concerned about
this crisis.
Brief answer, maybe yes or no. I believe that if this tax
bill passes in the near future, there will be brought to the
floor of the House and the Senate a trillion-dollar cut in
Medicaid. That was in the Republican budget.
Question: What happens to your programs if a trillion
dollars in Medicaid is cut? Very briefly.
Dr. Abubaker. I'm not sure of the financial implications of
this issue.
Senator Sanders. Ms. Boss.
Ms. Boss. It's a really simple answer. I think all of our
efforts are disintegrated, honestly. Our access to treatment is
foundational, and Medicaid supports access to treatment.
Senator Sanders. Thank you.
Ms. Magermans, a trillion-dollar cut?
Ms. Magermans. The PDMP greatly benefits from federal
financial support.
Senator Sanders. Secretary Tilley.
Secretary Tilley. Again, assuming a trillion-dollar cut, I
understand if you took that away from Kentucky, let me say
this. Again, I don't think access always equals outcomes. I do
have a real concern. We need money. We need it to come in other
targeted ways, whether it comes to us--I'm not concerned about
how it comes to us, but it needs to come to us with very
targeted, surgical--if those are strings, so be it.
Senator Sanders. If your Medicaid funding is cut, it's
going to make your life a lot more difficult, will it not?
Secretary Tilley. Well, I think if we don't have money to
do the things we do today, there will be some challenges,
although we are fighting for waivers to maintain those levels
of funding.
Senator Sanders. Okay, last question. At the end of the
day, I think we are all in agreement that we have to do a
better job of prevention in a wide variety of things. Are we
doing as good a job--and I had a town meeting at the largest
high school in the State of Vermont on this issue. Are we doing
as good a job as we can reaching out to the young people and
explaining to them the dangers, that just beginning to dabble
in this issue of opioids can be a life-threatening decision? Do
we do a good enough job, Secretary Tilley, in reaching out to
the young people?
Secretary Tilley. No, sir. We are doing everything we can
at the moment, but we need to do twice that, and I think we
need to reach to even a younger age and talk to them like we're
talking today. Again, don't patronize young people, but we need
to tell them exactly what can happen and how dangerous these
things are.
Senator Sanders. Ms. Magermans, young people?
Ms. Magermans. I would definitely agree with his remarks.
Senator Sanders. Ms. Boss.
Ms. Boss. We have not, but a lot of our efforts that are
funded now for the Cures and the other federal legislation that
has passed are focusing on just that, and we're really trying
to up our game in that area.
Senator Sanders. Good.
Dr. Abubaker.
Dr. Abubaker. Senator, I said that in my opening statement,
education, and I meant education all the way from middle school
to medical school.
Senator Sanders. Thank you all. Thank you very much.
The Chairman. Thank you, Senator Sanders.
Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chairman.
While the opioid epidemic continues to ravage the country
and my home State of Wisconsin, I have to say that I am proud
that Wisconsin is leading in a number of respects, including an
aggressive and innovative advancement like our state-of-the-art
Wisconsin Enhanced Prescription Drug Monitoring Program. We
have also implemented provider education requirements based on
the CDC Opioid Prescribing Guideline, as well as many other
reforms.
Before getting into a couple of specific questions about
that, I also want to associate myself with some of the previous
comments of my colleagues regarding the need for additional
resources. Whether it's the recommendation that we declare this
a national emergency, but whether that's just words or
resources too, that matters. Also I want to associate myself
with the observation that the matter that we are discussing on
the Senate floor today and potentially over the next several
days has an enormous impact on our ability to fight this
epidemic.
But, Ms. Magermans, as we've heard time and again in this
hearing, too often addiction begins with a legal prescription,
whether that's for a broken leg or other injury, chronic back
pain, oral surgery as we've been discussing, or it occurs
because of a doctor or nurse who recklessly over-prescribes
dangerous combinations of drugs, which happened actually at a
VA facility in Wisconsin in Tomah.
We need to have the real-time data about prescribing
practices not only to arm doctors with the tools they need to
care for the patients but also to ensure accountability for
those dangerous outliers.
I'd like you to elaborate a little bit further than you did
with Senator Cassidy about how the Wisconsin ePDMP enhances
provider education on safe prescribing, including with the CDC
guidelines, and also how it acts as an oversight tool that can
help manage over-prescribing.
Ms. Magermans. Sure, thank you. The alerts that are made
about patients and their prescription history are based on
criteria that come from the CDC guidelines, so having to do
with high levels of opioids or opioid/benzodiazepine overlap.
The alerts have information in them so that they are also an
education piece provided to the prescriber.
The chart that shows the opioid level of the patient and
whether or not there is an opioid/benzodiazepine overlap also
has information about why that is presented to the prescribers,
so the prescriber knows that there is a greater risk of
overdose with the concurrent prescription or a high level of
opioids. The benchmark lines at 50MME and 90MME come directly
from CDC recommendations, and then there are links within the
patient prescription history to report to the CDC for more
information.
Then within the prescribing practice metrics report for a
prescriber there is an additional education piece that just
explains some of the CDC guidelines, and that is one of the
oversight tools that a prescriber can use to do a self-
assessment to see how that prescriber compares to others in the
same specialty. Then a medical coordinator can also use that
same report to look for outliers within a specific health
system and provide education to the provider who might need
some education.
Senator Baldwin. Great. Just to clarify that last point, in
response to Senator Cassidy you were talking about the
potential of reporting your oversight with the Controlled
Substances Board and their ability to communicate with
licensing boards.
Ms. Magermans. Yes, this is correct. Data coming from the
PDMP is provided to the Controlled Substances Board. The
Controlled Substances Board will determine whether or not a
prescriber should be referred to the prescribing board for
potential discipline.
Senator Baldwin. I know we're watching the clock carefully,
but I did reference the misuse of opioids at a VA facility in
Wisconsin. It resulted in the tragic death of a Marine, and
working with his family we introduced bipartisan legislation
named in his honor, the Jason Simcakoski Memorial PROMISE Act.
Senator Capito and I worked together on that.
I guess my quick question for you is how is the Wisconsin
PDMP interacting with and sharing data with the VA, and are VA
providers submitting their prescription data?
Ms. Magermans. Yes, VA clinics in Wisconsin are submitting
dispensing data to the PDMP and have been for several years,
even before it was required of them. Then on the other end,
prescribers and other health care professionals in the VA
system can use the PDMP as a tool to help inform their
prescribing and dispensing decisions.
The Chairman. Thank you, Senator Baldwin.
Senator Murray.
Senator Murray. Mr. Chairman, I'm going to submit my
questions for the record. I just want to thank all of my
colleagues. Many of my questions were answered, but this has
been very helpful to us.
I would just reiterate that having the resources seems to
me a critical part of this discussion we can't leave out. But
thank you very much to all of you.
The Chairman. Thank you, Senator Murray.
Senator Whitehouse.
Senator Whitehouse. Thanks, Chairman. Thank you to the
panel, particularly Ms. Boss.
I'd like to get some advice from all of you. We've done the
CARA bill, which I think was a very comprehensive and thorough
piece of authorizing legislation, and we have the first half-
billion of the billion that we've been promised that has been
pushed out, in addition to the regular funding. I assume it
goes without saying that meeting our commitment to get you the
second half-billion this December in the funding bill would be
very important to the success of your efforts. Correct across
the board?
Ms. Magermans. Yes.
Senator Whitehouse. Yes. You're counting on it?
Ms. Boss. Yes.
Senator Whitehouse. One of the things that the CARA bill
required was better coordination among PDMPs. In different
states they didn't talk to each other, they distributed
information to different groups, the whole thing was a mess,
and we've tried to encourage that it be consolidated and
coordinated.
Ms. Magermans, what is your advice to us in terms of
getting a response from your peer group around the 50 states as
to what we should be doing and what we should be seeing?
Obviously, some may be laggards and they may not want to
participate in encouraging certain things. But if it were
possible for you and your colleagues or a majority of them to
come up with some recommendations to keep this moving forward,
I think that would be helpful. We're not seeing as much action
as I would like on this out of the Administration.
Do you think that's something that you would be capable of
doing, the group of government officials that oversee PDMPs? Or
is that asking too much?
Ms. Magermans. I think PDMP administrators would greatly
benefit from working together to learn from each other and to
implement best practices based on others? experiences.
Senator Whitehouse. Okay. Well, I will take advantage of
that and try to figure out if I can get access to your network
and start asking questions about where we should be right now,
because wherever we should be right now, I know we're not
there, and this is going to be worth some effort.
Ms. Boss, one of the things that Rhode Island has done that
is most novel has been to get those peer recovery coaches into
the emergency departments so that when somebody comes in
overdosed, they get a real opportunity for engagement before
they get put back out on the street again. In that context, I
have heard in a couple of places that the program bumps up
against privacy protections of the patient, and I wonder if
there are any lessons that we should take away from that
experience in terms of considering whether there should be
various types of exemptions from HIPAA, or whether there are
good workarounds to HIPAA.
As you know better than anyone, we had a terrible, terrible
tragedy with an adult son of parents who was heavily addicted
and had been in and out of the emergency department over and
over again, and by the time he finally died of an overdose, his
parents had never been notified of this recurring problem. I
think in every state there is a story to that effect.
To me, that's a bureaucratic failure. To me, we need to
find a way to get through that so that the parents, the loved
ones can be engaged, or if there's a complete breakdown of that
relationship that perhaps some kind of a special master or
something could be engaged.
But tell us about what the privacy problems are with the ED
program.
Ms. Boss. I think two different problems related to this.
One would be the fact that hospitals are not able to contact
family members without the express permission of the individual
in their care, and that would be a HIPAA violation if they did.
One of the workarounds that we're looking at is using our
health information exchange to get prior approval from
individuals before they hit the emergency room of who can be
contacted in an emergency, so at a moment when they're not in
the midst of, perhaps, active addiction, identifying, yes, you
can contact my whomever, and then being able to use that
through our health information exchange that the emergency
rooms have access to.
Senator Whitehouse. That would be something set up by folks
between their primary care provider and themselves early on, as
a matter of regular doctor visits.
Ms. Boss. Correct. The second is the ability to contact the
peers if the individual in that moment at the emergency room is
saying, no, I don't want to talk to a peer. One of the
workarounds that we've done is create a special authorization
that says you may not want to talk to a peer right now, you're
in withdrawal, you're not feeling well, you're embarrassed, but
can you sign this release and maybe they can contact you a day
or two from now.
We're piloting that right now and we are seeing significant
increases in the connections with peers. Because they're not
employees of the hospital, you need permission to contact them.
That release has been a workaround that looks, as a pilot, like
it's going to be pretty successful in engaging peers post the
emergency department.
Senator Whitehouse. My time is up, so I won't ask any more
questions, but I would invite anybody else who wishes to
respond to that question of the ED and the privacy issues to do
a response for the record. You'll be asked questions for the
record, and if you could add that to your questions for the
record, and if there's anything else.
I think this would be a very sensible place for us to do,
Mr. Chairman, a little bit more work as a Committee.
Thank you very much to the terrific panel.
The Chairman. Thank you, Senator Whitehouse.
I would say to the witnesses I have to leave, but Senator
Franken has agreed to chair the remainder of the hearing. We
have votes in a few minutes, so it won't be long. We have
Senator Casey, and we have Senator Warren, both of whom are
here. He'll call on them in that order for their 5 minutes of
questioning.
Let me thank each of you for very helpful testimony. I
think you can tell from the attendance here and the careful
questioning that we're very interested in learning from you
what we can do to help.
Senator Casey, why don't you go ahead? Senator Franken,
thank you for chairing the remainder of the hearing.
Senator Casey. Mr. Chairman, thank you very much.
I first want to ask unanimous consent that a statement from
the First Focus Campaign for Children, a statement for the
record, be included in the hearing record for today.
Senator Franken. [presiding] Without objection.
Senator Casey. Thank you.
I want to thank the panel members for your testimony and
for the work you do on this problem. I'm not sure any of us
have encountered a problem of this severity, and the
professionals in the room would know better than I. But we're
particularly grateful for your work and for your testimony
today.
I wanted to start with the question of funding. We've made,
I think, good progress coming together, Democrats and
Republicans, to recognize that this problem is so severe and so
substantial that we've got to work together. We did that with
the Comprehensive Addiction Recovery Act. We did that as well
when we added dollars in the Cures Act at the end of last year.
But we're still woefully short in terms of federal investment.
That's why I recently introduced Senate bill 2004, the so-
called Combatting the Opioid Epidemic Act. This bill would set
aside $45 billion over the next decade to address the epidemic,
and the lion's share of that, of course, would go to the
states.
If I can ask you this, if you can speak to your own state,
your own assessment of what would happen, what additional
actions might your state take if you had more federal funding
for this epidemic. I'll focus particularly on Ms. Boss and
Secretary Tilley, but anyone else who wants to comment on it is
certainly free to do that.
Ms. Boss. I thank you for that, and I was hoping to get a
question like this. Rhode Island's response has been pretty
comprehensive, but we know that there's more that we can do if
we had better access.
Some of the things that I would touch upon have been
mentioned before: pre-arrest diversion programs, very
important, keeping people out of the criminal justice system;
getting them access to treatment; rapid access through crisis
centers, Safe Stations were mentioned, things like that are
going to give rapid entry points to individuals to the
treatment that they need; affordable naloxone is something that
we're all concerned about, making sure that individuals can get
Narcan that need Narcan; women-specific treatment, PPW
programs. I know that CARA was looking at the importance of the
PPW programs.
Increasing funding for peers; effective prevention
campaigns. I think that the need for effective prevention and
reaching beyond just the opioid crisis has been mentioned
several times, but prevention, engaging families, youth, and
increasing the education to effective media campaigns.
Research, we need research. We're not there yet. There's
not a cure, and so we need better research. Finally, workforce
development. We won't put a dent in this unless we have a
workforce that's going to be able to address the need.
Thank you for that question.
Senator Casey. Thanks very much.
Secretary Tilley.
Secretary Tilley. Let me just reiterate, I concur with
everything Rebecca said and just would add a couple of things.
Take neonatal abstinence syndrome, for instance, any way you
cut it, its impact on the Medicaid budget, any way you cut it,
it's about a 10-to-1 return on investment. That's to the
taxpayer, not to mention easing the suffering of an infant.
Without that kind of funding--we had 1,300 babies born
addicted. We have hospitals working day and night to prevent
that kind of suffering. That would be the first and foremost
thing I would say.
I would also say that I do believe that you're working
together and locking arms on this. Senator McConnell called us
directly after the passage of CARE. We had a meeting in the
rural part of our state for 2 hours, and he listened in ways
that--to your question, how we could fund this. I am anxious
for the funding as well.
I do believe one thing that Rebecca would agree but did not
mention. One of the pillars of care is also law enforcement,
interdiction, the right kind. Again, in Kentucky we think we're
doing that with LEAD. We're also using the Justice Center's
Stepping Up model, the CSU Justice Center's Stepping Up model
to get the mentally ill out of jails and prisons and into
treatment, into the resources they need. We need that kind of
funding. In interdiction, we've got to cutoff the supply.
We need everything. We need prevention and treatment,
absolutely. We also need the right kind of interdiction, not
rounding up peddlers and addicts but actually cutting off the
head of the snake here and drying the supply up. Part of that
is the opioids, not just the heroin and fentanyl that's coming
in and being illegally manufactured in China and other places
across the globe. That has to stop. Our borders cannot allow
that to flow in like it is today. I would add that to it.
I'd simply say I'd be remiss if I didn't mention the long-
time efforts, too, of a group called UNITE in Kentucky,
established by my Chairman Emeritus, Hal Rogers, that you all
know well. We've been at this for so long in Kentucky that it
feels good to have so much attention paid to this. It doesn't
feel good in any way, but it's reassuring, so thank you for
your help.
Senator Casey. Thanks. I'll just end because I'm out of
time. But on the research question, the intent of the bill,
Senate bill 2004, is to dedicate about $250 million to that. On
neonatal abstinence, actually Senator McConnell and I already
passed a bill last year----
Secretary Tilley. Yes, sir.
Senator Casey----that directs HHS to focus on that issue.
Thank you very much, Mr. Chairman.
Senator Franken. Senator Baldwin.
I'm sorry. Elizabeth, Senator Warren.
Senator Warren. That's all right. Thank you, Mr. Chair.
I've talked with people all over Massachusetts who are on
the front lines in the opioid epidemic, and my staff and I also
conducted a statewide survey, and I'll just give you some of
the samples of what we heard.
At the High Point Treatment Center in Plymouth,
Massachusetts, the addiction, treatment, and recovery service
providers talked about the challenges they face in recruiting
and retaining enough treatment professionals. At the Salem Fire
Department, the first responders explained how they're saving
lives by expanding the use of overdose reversal medications. At
nearly every town hall, from Barnstable to Lowell to
Springfield, people shared stories about family members and
friends who have died or who continue to grapple with
addiction. In many of our communities, police officers have
focused on redirecting those with addiction away from
incarceration and into treatment by working hand in hand with
health care providers.
Secretary Tilley, I want to follow-up on that last point
and on the work you've already engaged in. I know you've done a
lot of work in Kentucky around criminal justice reform and
improving access to addiction treatment. Can you just say a
word about how important it is to have programs that get low-
level drug offenders into treatment and support services
instead of into prison?
Secretary Tilley. It's one of, if not the most important
thing we can do in criminal justice and in public health as it
relates to this addiction nightmare we're in.
Senator Warren. In both.
Secretary Tilley. In both, for so many reasons, because
there's only so much of our tax base that can be dedicated
anywhere in this state, in our state, or in the country at the
moment, and when you siphon off and cutoff the ability, because
of your corrections population or this incredible crush on your
core system or law enforcement, again you cutoff your ability
to attack it in the right ways.
Then I would also say that you actually make the problem
worse by incarcerating those who need treatment. It's
criminogenic. You cutoff hope. You make it more difficult for
them to get jobs with a felony on their record. We're working
on reentry every day. The country is waking up to the fact that
we have to give people that second and third chance at
opportunity when they have criminal records. Seventy million
Americans, because of this epidemic, in my mind, now have a
criminal record in this country, one out of every three adults.
I could take the next 2 minutes and 25 seconds to detail
each and every impact it's had on our system.
We have the highest percentage of children in Kentucky who
have had or have an incarcerated parent. We have 8,500 kids
today in foster care. If we could treat those in settings where
they could keep their children--and that can occur, by the
way--rather than having this incredible rate of per-capita
incarceration for women--by the way, this country, out of every
three women incarcerated in the world, one is here in the
United States, and Kentucky is not doing much better than that
as a state. We're working on that.
Senator Warren. Let me ask you, though, in following up on
this, I know that you mentioned earlier the LEAD program, the
Law Enforcement Assisted Diversion program from Senator
Murray's home state. We have a similar program in Massachusetts
that we began with the Police Assisted Addiction Recovery
Initiative, which was founded in Gloucester, Massachusetts. But
the LEAD program allows police officers to redirect low-level
drug offenders into community-based services instead of
charging them with a drug offense. As you point out, it saves
lives, saves money.
I just want to ask you, if you could, just underline for a
minute here, we talk often when we're talking about addiction
and how to fight back, we talk about the role of doctors, we
talk about the role of hospitals in doing this, but we rarely
talk about the role of supporting our police and the importance
of supporting our police in this, and I just wonder--we have
just a little tiny bit of time left. Could I ask you, Secretary
Tilley, to say a word about that?
Secretary Tilley. Absolutely. We have law enforcement
officers that, again, work within our cabinet in one sense or
another. By the way, thank you for the Angel Initiative,
Massachusetts. We mentioned that earlier. Kentucky became the
first to mimic that and is working well with our State Police
posts.
Having said that, police, again front line soldiers in this
regard, are overwhelmed, and they need more tools. Often times
I have chiefs tell me that they need more social workers,
frankly, in their departments to work with their officers, and
the officers themselves tell me they need more social work
capacity. We are training in things like crisis intervention,
de-escalation. That yields tremendous results.
I would point you to, quickly, the Data-Driven Justice
Initiative. It's now in the Arnold Foundation, law enforcement
assisted diversion we are using now which began in Seattle,
again Stepping Up, and all manner of ways to allow first
responders to be trained in how to meet people in these
situations and divert them away from what is a crush on local
jails, not to mention state prisons. Again, I think the
redirection of these offenders is one of the most important
things we could talk about today.
Senator Warren. I really do appreciate that and couldn't
agree more with your point. I led a number of my colleagues in
calling for more funding to support LEAD and other diversion
programs like it. Communities and police departments need every
dollar they can get to be able to wage this battle.
When I talk to people in Massachusetts who are on the front
lines in this epidemic, one thing that's clear to me is that
President Trump's promises to treat the epidemic as a public
health emergency won't get the job done unless there are also
significant increases in federal funding to support them. Our
patients and our families deserve this.
Thank you.
Thank you, Mr. Chairman.
Senator Franken. Thank you, Senator Warren.
This whole area of criminal justice in the 21st Century
Cures Act was proud to pass the Comprehensive Justice and
Mental Health Act, which is about coordinating the criminal
justice system and not incarcerating people who have addiction
or mental health issues. I'm going to submit questions for the
record on housing and doing that kind of coordinated care where
you get facilitators to work with people who--very similar to
what, Ms. Boss, you're doing in Rhode Island.
Thank you all.
The hearing record will remain open for 10 days. Members
may submit additional information for the record within that
time if they would like.
The HELP Committee will meet again on Tuesday, December
5th, at 10 a.m. for a hearing on Department of Education and
Department of Labor nominations.
Thank you for being here again today. Thank you all for the
work that you do day in and day out.
The Committee will stand adjourned.

[Whereupon, at 12:15 p.m., the hearing was adjourned.]

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